Contract Holder Group Agreement Effective Date: January 1, 2012 TheAetna Health Inc. Certificate is amended as follows:
The Special Enrollment Period provision under the Eligibility and Enrollment section is deleted and replaced with the following:
6. Special Enrollment Period.
An eligible individual and eligible dependents may be enrolled during special enrollment periods. A special enrollment period may apply when an eligible individual or eligible dependent loses other health coverage or when an eligible individual acquires a new eligible dependent through marriage, birth, adoption or placement for adoption.
Special Enrollment Period for Certain Individuals Who Lose Other Health Coverage:
An eligible individual or an eligible dependent may be enrolled during a special enrollment period, if requirements a, b, c and d are met:
a. the eligible individual or the eligible dependent was covered under another group health plan or other health insurance coverage when initially eligible for coverage under HMO;
b. the eligible individual or eligible dependent previously declined coverage in writing under HMO;
c. the eligible individual or eligible dependent loses coverage under the other group health plan or other health insurance coverage for 1 of the following reasons:
i. the other group health coverage is COBRA continuation coverage under another plan, and the COBRA continuation coverage under that other plan has since been exhausted; or
ii. the other coverage is a group health plan or other health insurance coverage, and the other coverage has been terminated as a result of loss of eligibility for the coverage or employer contributions towards the other coverage have been terminated.
Loss of eligibility includes the following:
• a loss of coverage as a result of legal separation, divorce or death;
• termination of employment;
• reduction in the number of hours of employment;
• any loss of eligibility after a period that is measured by reference to any of the foregoing;
• termination of HMO coverage due to Member action-movement outside of the HMO’s service area; and also the termination of health coverage including Non-HMO, due to plan termination.
• plan ceases to offer coverage to a group of similarly situated individuals;
• cessation of a dependent’s status as an eligible dependent
• termination of benefit package
Loss of eligibility does not include a loss due to failure of the individual or the participant to pay Premiums on a timely basis or due to termination of coverage for cause as referenced in the Termination of Coverage section of this Certificate; and
d. the eligible individual or eligible dependent enrolls within 30-31 days of the loss.
The Effective Date of Coverage will be the first day of the first calendar month following the date the completed request for enrollment is received.
The eligible individual or the eligible dependent enrolling during a special enrollment period will not be subject to late enrollment provisions, if any, described in this Certificate.
Special Enrollment Period When a New Eligible Dependent is Acquired:
When a new eligible dependent is acquired through marriage, birth, adoption or placement for adoption, the new eligible dependent (and, if not otherwise enrolled, the eligible individual and other eligible dependents) may be enrolled during a special enrollment period.
The special enrollment period is a period of 30-90 days, beginning on the date of the marriage, birth, adoption or placement for adoption (as the case may be). If a completed request for enrollment is made during that period, the Effective Date of Coverage will be:
• In the case of marriage, the first day of the first calendar month following the date the completed request for enrollment is received.
• In the case of a dependent’s birth, adoption or placement for adoption, the date of such birth, adoption or placement for adoption.
The eligible individual or the eligible dependents enrolling during a special enrollment period will not be subject to late enrollment provisions, if any, described in this Certificate.
The Definition of “Creditable Coverage” is deleted and replaced with the following definition:
• Creditable Coverage. Coverage of the Member under a group health plan (including a governmental or church plan), a health insurance coverage (either group or individual insurance), Medicare, Medicaid, a military-sponsored health care (CHAMPUS), a program of the Indian Health Service, a State health benefits risk pool, the Federal Employees Health Benefits Program (FEHBP), a public health plan, including coverage received under a plan established or maintained by a foreign country or political subdivision as well as one established and maintained by the government of the United States, any health benefit plan under section 5(e) of the Peace Corps Act and the State Children’s Health Insurance Program (S-Chip). Creditable Coverage does not
include coverage only for accident; Workers’ Compensation or similar insurance; automobile medical payment insurance; coverage for on-site medical clinics; or limited-scope dental benefits, limited-scope vision benefits, or long-term care benefits that are provided in a separate policy.
AETNA HEALTH INC.
(MAINE)
CERTIFICATE OF COVERAGE AMENDMENT
Contract Holder Group Agreement Effective Date: January 1, 2012
The Aetna Health Inc. HMO Certificate is amended as follows:
The Definitions section of the Certificate is hereby amended to add the following:
Residential Treatment Facility – (Mental Disorders)
This is an institution that meets all of the following requirements:
• On-site licensed Behavioral Health Provider 24 hours per day/7 days a week.
• Provides a comprehensive patient assessment (preferably before admission, but at least upon admission).
• Is admitted by a Physician.
• Has access to necessary medical services 24 hours per day/7 days a week.
• Provides living arrangements that foster community living and peer interaction that are consistent with developmental needs.
• Offers group therapy sessions with at least an RN or Masters-Level Health Professional.
• Has the ability to involve family/support systems in therapy (required for children and adolescents;
encouraged for adults). practitioner, and (2) function under the direction/supervision of a licensed psychiatrist (Medical Director).
• Has individualized active treatment plan directed toward the alleviation of the impairment that caused the admission.
• Provides a level of skilled intervention consistent with patient risk.
• Meets any and all applicable licensing standards established by the jurisdiction in which it is located.
• Is not a Wilderness Treatment Program or any such related or similar program, school and/or education service.
Residential Treatment Facility – (Alcoholism and Drug Abuse) This is an institution that meets all of the following requirements:
• On-site licensed Behavioral Health Provider 24 hours per day/7 days a week
• Provides a comprehensive patient assessment (preferably before admission, but at least upon admission).
• Is admitted by a Physician.
• Has access to necessary medical services 24 hours per day/7 days a week.
• If the member requires detoxification services, must have the availability of on-site medical treatment 24 hours per day/7days a week, which must be actively supervised by an attending Physician.
• Provides living arrangements that foster community living and peer interaction that are consistent with developmental needs.
• Offers group therapy sessions with at least an RN or Masters-Level Health Professional.
• Has the ability to involve family/support systems in therapy (required for children and adolescents;
encouraged for adults).
• Provides access to at least weekly sessions with a Psychiatrist or psychologist for individual psychotherapy.
• Has peer oriented activities.
• Services are managed by a licensed Behavioral Health Provider who, while not needing to be individually contracted, needs to (1) meet the HMO credentialing criteria as an individual practitioner, and (2) function under the direction/supervision of a licensed psychiatrist (Medical Director).
• Has individualized active treatment plan directed toward the alleviation of the impairment that caused the admission.
• Provides a level of skilled intervention consistent with patient risk.
• Meets any and all applicable licensing standards established by the jurisdiction in which it is located.
• Is not a Wilderness Treatment Program or any such related or similar program, school and/or education service.
• Ability to assess and recognize withdrawal complications that threaten life or bodily functions and to obtain needed services either on site or externally.
• 24-hours per day/7 days a week supervision by a Physician with evidence of close and frequent observation.
• On-site, licensed Behavioral Health Provider, medical or substance abuse professionals 24 hours per day/7 days a week.
AETNA HEALTH INC.
(MAINE)
CERTIFICATE OF COVERAGE AMENDMENT
Contract Holder Group Agreement Effective Date: January 1, 2012
The Dependent Eligibility section of the Aetna Health Inc. HMO Certificate is hereby amended to add the following: