Aetna Savings Plus Plan Guide

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Aetna Savings Plus Plan Guide

For businesses with 2 – 50 eligible employees in Northeast Ohio

Plans effective August 1, 2011

Aetna Avenue

®

Your Destination for Small Business Solutions

®

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The Aetna Savings Plus plans are helping Northeast Ohio small businesses

access health services that fit their needs and their budgets. They give

members access to an affordable network of health providers right in their

own community.

Same quality local care at a lower cost

The Aetna Savings Plus plans provide Northeast Ohio members with the same

types of coverage as other Aetna medical plans, but at a lower premium cost.

Savings are generated through the use of the Savings Plus network, a quality

network of local health care providers. The plans also:

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Cover doctor’s visits, hospital stays and preventive care

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Include prescription drugs

n

Provide access to a secure member self-service website

How do the Savings Plus plans work?

There are three different Aetna Savings Plus plans in Northeast Ohio, giving

small businesses the flexibility and choice to best meet their needs. Savings Plus

plans use the Aetna Managed Choice

®

_{POS Open Access network.}

Each Savings Plus plan has three levels of benefits:

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Level 1:

When members use the Savings Plus network, they realize

maximum savings.

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Level 2:

When members use the Non-Designated Network Providers,

they realize standard savings.

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Level 3:

When members use out-of-network providers, they will see the

highest member cost.

While members have the freedom to receive care from any hospital or

specialist, they realize the highest benefit level and the lowest out-of-pocket

costs when they access care through the Savings Plus network.

All Savings Plus plans include coverage for doctor’s visits, hospital stays,

preventive care, pharmacy and more. (Refer to the benefits summaries on

pages 4 – 6 for more details.) Each plan offers three levels of benefits to

your employees.

Premiums and out-of-pocket expense levels vary — select the

plan that’s right for you and your employees.

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Aetna makes it easier to

manage your health plan

Savings Plus plans include access to a robust suite of resources and online

tools that save you time and money while helping your employees make

better health decisions.

Easy-to-navigate plans

Aetna’s small group health benefits and insurance plans are easy to set up,

administer and use. Once enrolled, you will have access not only to your

health insurance benefits, but also to online resources and information to help

you and your employees make more informed decisions about your health.

Aetna e-Business for plan sponsors

Aetna will help you save time and manage your benefits through a suite

of innovative, easy-to-use online tools, supporting enrollment transactions.

The benefits enrollment process is easier than ever, replacing paper-based

enrollment with a secure, comprehensive electronic solution.

More benefits for small businesses

Aetna’s Savings Plus clients can tap into corporate buying power through

Aetna’s Resource Connection

SM

_{, which features discounted goods and}

services. While not insurance, these discounts* can help you save on

office supplies, HR support, payroll, technology assistance and more.

Let Aetna be

your guide

With 150 years of experience,

we can deliver the right solution

for your small business.

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Aetna Savings Plus

service areas

for Northeast Ohio

Lake County

Ashtabula

_County

Geauga

County

Cuyahoga

County

Cuyahoga County

ZIP Code City

44022 Chagrin Falls 44117 Euclid 44119 Euclid 44123 Euclid 44124 Lyndhurst 44124 Mayfield Heights 44132 Euclid 44139 Solon 44143 Mayfield 44143 Mayfield Heights 44143 Mayfield Village 44143 Euclid 44143 Highland Heights

Geauga County

ZIP Code City

44023 Auburn Township 44023 Bainbridge Township 44023 Chagrin Falls 44024 Chardon 44024 Concord Township 44026 Chesterland 44064 Montville 44072 Parkman 44072 Novelty 44073 Novelty 44086 Thompson

Ashtabula County

ZIP Code City

44041 Geneva

Lake County

ZIP Code City

44045 Grand River 44057 Madison 44060 Mentor

44060 Mentor on the Lake 44061 Mentor 44077 Concord 44077 Fairport Harbor 44077 Painesville 44081 Perry 44092 Wickliffe 44092 Willoughby Hills 44094 Kirtland 44094 Waite Hill 44094 Willoughby 44094 Willoughby Hills 44095 Eastlake 44095 Lakeline 44095 Timberlake 44095 Willoughby 44095 Willowick 44096 Willoughby 44097 Eastlake 44097 Willoughby

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Underwriting guidelines

MULTI-OPTION OFFERINGS

Greater employee choice

Employers can offer any 3 of the 17 available

standard plan designs, including Savings Plus plans.

Flexibility and affordability

Employers can create a customized benefits package from

any of our plan types and plan designs. Aetna offers a

variety of plans at different price points. Employers may

designate a level of contribution that meets their budget.

Total freedom

Aetna offers 17 plan choices that range in price and

benefits to help meet each individual employee’s needs,

whether they are lower premiums or lower out-of-pocket

costs at the time services are received.

Easy administration

Setting up this program is simple:

1. The employer chooses up to 3 plans to offer on the

Employer Application.

2. The employer chooses how much to contribute.

3. Each employee chooses the plan that’s right for him or her.

Aetna Savings

Plus Plans

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Underwriting guidelines for the Savings Plus plans follow the same guidelines as

the Ohio Small Group Standard portfolio.

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Can be offered as a triple option next to a Standard plan in the portfolio. n

Cannot be offered to employees out of state (OOS) or outside one of the

specified counties/zip codes.

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Eligible employees must reside in the Savings Plus area (see map opposite page):

– Lake – Geauga – Cuyahoga – Ashtabula

MuLtI-OPtIOn OffErInGS

target audience Every small business with 5+ enrolled employees

Plan choices Up to 3 of the 17 available plans

Minimum participation

1 – 4 enrolled employees

5 – 50 enrolled employees Choice of one plan Choice of up to 3 plans, minimum of 1 employee in each plan

Employer contribution n

50% of employee-only premium or a minimum defined contribution of $120 per employee n

The employer cannot fund the deductible in excess of 50% annually, whether through an

HRA, HSA or any other funding arrangement

n

Coverage can be denied based on inadequate or excess contributions

rAtInG OPtIOnS

1 – 4 enrolled employees Tabular

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Easily locate provider information online

Go to http://www.aetna.com/docfind/custom/ohsavingsplus designates Savings Plus providers.

* Managed Choice POS Open Access (OAMC) network providers.

AEtnA SMALL GrOuP MEDICAL PLAnS: Ohio Savings Plus Plan Options*

PLAn OPtIOnS OH SAvInGS PLuS OAMC $1000 80%

MEMBEr BEnEfItS Level 1: Savings Plus Designated Providers* — Maximum Savings Level 2: Non-Designated Network Providers* — Standard Savings Level 3: Out-of-Network Providers** PCP referrals required No No No Plan Coinsurance

(Applies to most services) 80% 50% 50%

Calendar-Year Deductible

(Level 1 accumulates separately from Levels 2 and 3 combined)

$1,000 Individual

$3,000 Family $7,500 Individual $22,500 Family

Calendar-Year Out-of-Pocket Maximum

(Includes deductible; excludes copayments and member coinsurance payments for DME; Level 1 accumulates separately from Levels 2 and 3 combined)

$4,000 Individual

Lifetime Maximum Benefit Unlimited

Primary Physician Office visit $30 copay, deductible waived 50% 50%

Specialist Office visit $50 copay, deductible waived 50% 50%

Outpatient Lab $50 copay, deductible waived 50% 50%

Outpatient X-ray $50 copay, deductible waived 50% 50%

Outpatient Complex Imaging (CAT, MRI, MRA/MRS

and PET scans; precertification required) 80% 50% 50%

Well Baby and Child Exams/Adult Physical Exams/Immunizations/routine GYn Exams/ routine Mammograms

(Age/frequency schedules apply)

$0 copay, deductible waived $0 copay, deductible waived 50%

routine Eye Exam

(One exam per 24 months; Levels 1, 2 and 3 combined) $0 copay, deductible waived $0 copay, deductible waived 50%

Inpatient Hospital 80% 50% 50%

Outpatient Surgery 80% 50% 50%

Emergency room

(Copay waived if admitted) $200 copay, deductible waived

urgent Care $50 copay, deductible waived 50% 50%

Chiropractic (Limited to 12 visits per calendar year;

Levels 1, 2 and 3 combined) $50 copay, deductible waived 50% 50%

Outpatient Physical/Occupational therapy/ Speech therapy (40 visits per calendar year; Levels 1, 2 and 3 combined)

$50 copay, deductible waived 50% 50%

Prescription Drugs

(Retail: per 30-day supply; mail order: two-and-a-half

times retail copay; 31- to 90-day supply; includes insulin) $15/$35/$60/$150 70% after $15/$35/$60/$150

90-Day rx transition of Coverage

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See page 7 for footnotes.

AEtnA SMALL GrOuP MEDICAL PLAnS: Ohio Savings Plus Plan Options*

$2,500 Individual

$5,000 Individual

Primary Physician Office visit $30 copay, deductible waived 50% 50%

Specialist Office visit $50 copay, deductible waived 50% 50%

Outpatient Lab $50 copay, deductible waived 50% 50%

Outpatient X-ray $50 copay, deductible waived 50% 50%

Emergency room

(Copay waived if admitted) $200 copay, deductible waived

urgent Care $50 copay, deductible waived 50% 50%

Levels 1, 2 and 3 combined) $50 copay, deductible waived 50% 50%

$50 copay, deductible waived 50% 50%

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AEtnA SMALL GrOuP MEDICAL PLAnS: Ohio Savings Plus Plan Options*

$4,000 Individual

$7,000 Individual

Primary Physician Office visit 80% 50% 50%

Specialist Office visit 80% 50% 50%

Outpatient Lab 80% 50% 50%

Outpatient X-ray 80% 50% 50%

Emergency room

(Copay waived if admitted) 80%

urgent Care 80% 50% 50%

Levels 1, 2 and 3 combined) 80% 50% 50%

80% 50% 50%

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This is a partial description of the benefits available; for more information, refer to the specific plan design summary. The dollar amount copayments indicate what the member is required to pay and the percentage coinsurance indicates what Aetna is required to pay. The deductible applies to all medical benefits unless otherwise stated.

* Managed Choice POS Open Access (OAMC) network providers. Easily locate Savings Plus Designated providers online. Go to Aetna DocFind: http://aetna.com/docfind. In the left column, scroll down to Other Directories. Select Savings Plus — Ohio.

** We cover the cost of services based on whether doctors are “in network” or “out of network.” We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this out-of-network care.

You may choose a provider (doctor or hospital) in our network, or you may choose to visit an out-of-network provider. If you choose a doctor who is out of network, your Aetna health plan may pay some of that doctor’s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital.

When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the “recognized” or “allowed” amount. When you choose out- of-network care, Aetna recognizes an amount based on what Medicare pays for these services. The government sets the Medicare rate.

Your doctor sets his or her own rate to charge you. It may be higher — sometimes much higher — than what your Aetna plan recognizes. Your doctor may bill you for the dollar amount that Aetna doesn’t recognize. You must also pay any coinsurance and deductibles under your plan. No dollar amount above the “recognized charge” counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits, visit www.aetna.com and type “how Aetna pays” into the search box.

You can avoid these extra costs by getting your care from Aetna’s broad network of health care providers. Go to www.aetna.com and click on “Find a Doctor” on the left side of the page. If you are already a member, sign on to your Aetna Navigator®_{member site.}

This applies when you choose to get care out of network. When you have no choice (for example, an emergency room visit or other emergency services), we will pay the bill as if you got care in network. You pay cost sharing and deductibles for your in-network level of benefits, and you should contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles.

*** Transition of Coverage for Prior Authorization helps members of new groups to transition to Aetna by providing a 90-calendar-day opportunity, beginning on the group’s initial effective date, during which time prior authorization requirements will not apply to certain drugs. Once the 90 calendar days have expired, prior authorization edits will apply to all drugs requiring prior authorization as listed in the formulary guide. Members who have claims paid for a drug requiring prior authorization during the Transition of Coverage period may continue to receive this drug after the 90 calendar days and will not be required to obtain a prior authorization.

Note: For a summary list of Limitations and Exclusions, refer to page 8.

Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain prior approval for certain services, such as non-emergency hospital care.

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These plans do not cover all health

care expenses and include exclusions

and limitations. Members should refer

to their plan documents to determine

which health care services are covered

and to what extent.

The following is a partial list of services

and supplies that are generally not

covered. However, the plan documents

may contain exceptions to this list based

on state mandates or the plan design

purchased.

Medical limitations and exclusions

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All medical or hospital services not

specifically covered in, or which

are limited to or excluded in, the

plan documents

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Charges related to any eye surgery

mainly to correct refractive errors

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Cosmetic surgery, including breast

reduction

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Custodial care

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Dental care and X-rays

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Donor egg retrieval

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Experimental and investigational

procedures

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Hearing aids

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Immunizations for travel or work

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Infertility services, including, but not

limited to, artificial insemination and

advanced reproductive technologies

such as IVF, ZIFT, GIFT, ICSI and other

related services, unless specifically

listed as covered in the plan

documents

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Nonmedically necessary services

or supplies

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Orthotics

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Over-the-counter medications

and supplies

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Reversal of sterilization

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Services for the treatment of sexual

dysfunction or inadequacies, including

therapy, supplies or counseling and

prescription drugs

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Special-duty nursing

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Weight-control services, including

surgical procedures, medical

treatments, weight-control/-loss

programs, dietary regimens and

supplements, appetite suppressants

and other medications; food or food

supplements, exercise programs,

exercise or other equipment; and

other services and supplies that are

primarily intended to control weight

or treat obesity, including morbid

obesity or for the purpose of weight

reduction, regardless of the existence

of comorbid conditions

Pre-existing conditions

exclusion provision

These plans impose a pre-existing

conditions exclusion, which may be

waived in some circumstances (that

is, creditable coverage) and may not

be applicable to you. A pre-existing

conditions exclusion means that if you

have a medical condition before coming

to our plan, you might have to wait a

certain period of time before the plan

will provide coverage for that condition.

This exclusion applies only to conditions

for which medical advice, diagnosis

or treatment was recommended or

received or for which the individual

took prescribed drugs within six months.

Pre-existing conditions exclusion

provisions are waived for any individual

under the age of 19.

Generally, this period ends the day

before your coverage becomes effective.

However, if you were in a waiting period

for coverage, the six-month period

ends on the day before the waiting

period begins. The exclusion period, if

applicable, may last up to 12 months

from your first day of coverage, or if

you were in a waiting period, from the

first day of your waiting period. If you

had prior creditable coverage within 90

days immediately before the date

you enrolled under this plan, then the

pre-existing conditions exclusion in

your plan, if any, will be waived.

If you had no prior coverage within

the 90 days prior to your enrollment

date (either because you had no prior

coverage or because there was more

than a 90-day gap from the date your

prior coverage terminated to your

enrollment date), we will apply your

plan’s pre-existing conditions exclusion.

In order to reduce or possibly eliminate

your exclusion period based on your

creditable coverage, you should

provide us a copy of any Certificates

of Creditable Coverage you may

have. Please contact your Aetna

Member Services representative at

1-888-80-AEtnA if you need

assistance in obtaining a Certificate of

Creditable Coverage from your prior

carrier or if you have any questions

on the information noted above.

The pre-existing conditions exclusion

does not apply to pregnancy nor to

a child who is enrolled in the plan

within 31 days after birth, adoption

or placement for adoption. Note: For

late enrollees, coverage will be delayed

until the plan’s next open enrollment;

the pre-existing conditions exclusion will

be applied from the individual’s effective

date of coverage.

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This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location. Health benefits and insurance plans contain exclusions and limitations. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Plan features and availability may vary by location and group size. Plan For Your Health is a public education program from Aetna and The Financial Planning Association. Providers are independent contractors and not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna’s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacy subsidiary of Aetna Inc. that operates through mail order.

Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to

Contact us

for more information regarding the Aetna Savings Plus Plans

for northeast Ohio, please contact your Aetna Small Group

account executive or our Broker Services team

toll-free at 1-888-380-7821.

Aetna Avenue

®