Aetna Life Insurance Company
Hartford, Connecticut 06156
Extraterritorial Certificate Rider
(GR-9N-CR1)Policyholder:
Choctaw Enterprises
Group Policy No.:
GP-819977
Rider:
Kentucky ET Medical (OAMC)
Issue Date:
March 31, 2010
Effective Date:
January 1, 2010
This certificate rider forms a part of the booklet certificate issued to you by Aetna describing the benefits provided under the policy specified above. This extraterritorial certificate-rider takes the place of any other medical
extraterritorial certificate-rider issued to you on a prior date.
Note: The provisions identified herein are specifically applicable ONLY for:
Benefit plans which have been made available to you and/or your dependents by your Employer;
Benefit plans for which you and/or your dependents are eligible;
Benefit plans which you have elected for you and /or your dependents;
The benefits in this rider are specific to residents of Kentucky. These benefits supersede any provision in your booklet certificate to the contrary unless the provisions in your certificate result in greater benefits. You are only entitled to these benefits, if you are a resident of Kentucky, and if the benefit value exceeds those benefits covered under the group policy and booklet certificate.
Routine Mammograms
Covered expenses include charges incurred for routine cancer screening as follows:
One screening mammogram, for a person age 35 but less than 40.
One mammogram every two years for a person age 40 but less than 50.
One mammogram each calendar year, for a person age 50 or over.
A mammogram for women who have been diagnosed with breast disease, upon referral by a health care practitioner acting within the scope of the practitioner’s license.
Diabetic Equipment and Self-Management Education Expenses
(GR-9N 11-135-01 OK)
Covered expenses include charges for the following expenses incurred in connection with the treatment of diabetes (including insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin using diabetes):
Equipment;
Supplies;
Outpatient self-management training and education (including medical nutrition therapy);
Medications.
The treatment must be prescribed by a physician.
Outpatient self management education must be provided by a certified, registered or licensed provider with expertise in diabetes.
Charges incurred for the following are not included:
a diabetic education program whose only purpose is weight control; or which is available to the public at no cost; or
a general program not just for diabetics; or
a program made up of services not generally accepted as necessary for the management of diabetes.
Pervasive Mental Developmental Disorder (Autism) Expenses
The charges made for the services of a health care provider for rendering Pervasive Mental Developmental Disorder Services to a child who is at least 2 years of age and under 22 years of age are included as covered expenses.
Pervasive Mental Developmental Disorder Services means:
therapeutic services (such as psychotherapy and speech and language therapy); and
rehabilitative services (such as occupational and physical therapy); and
respite services. Not included are charges:
for services rendered by a person who resides with you or who is part of your family; or
for services paid for under any other part of this Plan.
Not more than the Pervasive Mental Developmental Disorder (Autism) Monthly Maximum will be payable for Pervasive Mental Developmental Disorder Services Expenses incurred by a person in any one calendar month.
PLAN FEATURES NETWORK OUT-OF-NETWORK
Pervasive Mental Development Disorder (Autism) Expenses (GR-9N 11-100-01) (Autism) Monthly Maximum $500 $500
Alcoholism, Substance Abuse and Mental Disorders Treatment
(GR-9N 11-170-01 OK)(GR-9N-S-11-175-01)
Covered expenses include charges made for the treatment of alcoholism, substance abuse and mental disorders
by behavioral health providers.
Important Notice
Not all types of services are covered. For example, educational services and certain types of therapies are not covered. See the Health Plan Exclusions and Limits section for more information.
Alcoholism and Substance Abuse
<11SECTION175>Covered expenses include charges made for the treatment of alcoholism and substance abuse by behavioral health providers. In addition to meeting all other conditions for coverage, the treatment must meet the following criteria:
Inpatient Treatment for Alcoholism and Substance Abuse
The plan covers room and board at the semi-private room rate and other services and supplies provided during your stay in a psychiatric hospital or residential treatment facility, appropriately licensed by the State Department of Health or its equivalent.
Coverage includes:
Treatment in a hospital for the medical complications of alcoholism or substance abuse.
“Medical complications” include detoxification, electrolyte imbalances, malnutrition, cirrhosis of the liver, delirium tremens and hepatitis.
Treatment in a hospital, when the hospital does not have a separate treatment facility section.
Outpatient Treatment for Alcoholism and Substance Abuse
The plan covers outpatient treatment of alcoholism or substance abuse.
The plan covers partial hospitalization services (more than 4 hours, but less than 24 hours per day) provided in a facility or program for the intermediate short-term or medically-directed intensive treatment of alcoholism or
substance abuse. The partial hospitalization will only be covered if you would need inpatient treatment if you were not admitted to this type of facility.
Partial Confinement Treatment for Alcoholism and Substance Abuse
Covered expenses include charges made for partial confinement treatment provided in a facility or program for the intermediate short-term or medically-directed intensive treatment of alcoholism or substance abuse.
The partial confinement treatment will only be covered if you would need a hospital stay if you were not admitted to this type of facility.
Important Reminder:
Inpatient care must be precertified by Aetna. Refer to How the Plan Works for more information about
precertification.
Alcoholism Treatment Services
The plan pays the charges of a physician, hospital or treatment facility for effective treatment of alcoholism including emergency detoxification.
For charges of a treatment facility to be covered upon completion of the phase of program of treatment by the patient under the guidance and direction of a physician or professional designated by a physician.
Coverage may be subject to the benefit limits shown in the Summary of Benefits.
PLAN FEATURES NETWORK OUT-OF-NETWORK
Inpatient Treatment of Alcoholism and Substance Abuse (GR-9N 11-070-01)
Inpatient Treatment 80% per admission after Calendar
Outpatient Treatment of Alcoholism and Substance Abuse
Outpatient Treatment $50 per visit copay then the plan pays 100%
No deductible applies
75% per visit after Calendar Year
deductible
Treatment of Mental Disorders
<11SECTION170>Covered expenses include charges made for the treatment of other mental disorders by behavioral health providers. In addition to meeting all other conditions for coverage, the treatment must meet the following criteria:
There is a written treatment plan prescribed and supervised by a behavioral health provider;
The plan includes follow-up treatment; and
The plan is for a condition that can favorably be changed.
Benefits are payable for charges incurred in a hospital, psychiatric hospital, residential treatment facility or
behavioral health provider's office for the treatment of mental disorders as follows:
Inpatient Treatment
Covered expenses include charges for room and board at the semi-private room rate, and other services and supplies provided during your stay in a hospital, psychiatric hospital or residential treatment facility. Inpatient benefits are payable only if your condition requires services that are only available in an inpatient setting.
Partial Confinement Treatment
Covered expenses include charges made for partial confinement treatment provided in a facility or program for the intermediate short-term or medically-directed intensive treatment of a mental disorder. Such benefits are payable if your condition requires services that are only available in a partial confinement treatment setting.
Outpatient Treatment
Covered expenses include charges for treatment received while not confined as a full-time inpatient in a hospital,
psychiatric hospital or residential treatment facility.
The plan covers partial hospitalization services (more than 4 hours, but less than 24 hours per day) provided in a facility or program for the intermediate short-term or medically-directed intensive treatment. The partial
hospitalization will only be covered if you would need inpatient care if you were not admitted to this type of facility.
Important Reminder:
Inpatient care must be precertified by Aetna. Refer to the How the Plan Works section for more information about
precertification.
PLAN FEATURES NETWORK OUT-OF-NETWORK
Inpatient Treatment of Mental Disorders (GR-9N 11-060-01)(GR-9N 10-060 01)
Mental Disorders 80% per admission after the
Charges made for the following are not covered:
Charges the recipient has no legal obligation to pay; or the charges would not be made if the recipient did not have coverage (to the extent exclusion is permitted by law) including:
− Care while in the custody of a governmental authority; except if the covered person is incarcerated in a local or regional jail prior to a conviction of a felony.
Coordination of Benefits -
What Happens When
There is More Than One
Health Plan
(GR-9N 33-005-01-OK)
When Coordination of Benefits Applies
This Coordination of Benefits (COB) provision applies to This Plan when you or your covered dependent has health coverage under more than one Plan. “Plan” and “This Plan” are defined herein. If any provision of this section is deemed to be invalid or illegal, that provision shall be fully severable and the remaining provisions of this section shall continue in full force and effect. The Order of Benefit Determination Rules below determines which Plan will pay as the primary plan. The primary plan pays first without regard to the possibility that another plan may cover some expenses. A secondary plan pays after the primary plan and may reduce the benefits it pays so that payments from all group plans do not exceed 100% of the total allowable expense. If you are covered by more than 1 health benefit Plan, you should file all your claims with each Plan.
Plan. Any Plan providing benefits or services by reason of health care or treatment, which benefits or services are provided by one of the following:
Group or non-group, blanket, or franchise health insurance policies issued by insurers, including health care service contractors;
Other prepaid coverage under service plan contracts, or under group or individual practice;
Uninsured arrangements of group or group-type coverage;
Labor-management trustee plans, labor organization plans, employer organization plans, or employee benefit organization plans;
Medicare or other governmental benefits;
Other group-type contracts. Group type contracts are those which are not available to the general public and can be obtained and maintained only because membership in or connection with a particular organization or group. Medical benefits coverage in a group, group-type, and individual automobile “no-fault” and traditional automobile “fault” type contracts are not Plans.
If the Plan includes medical, prescription drug, dental, vision and hearing coverage, those coverages will be considered separate plans. For example, Medical coverage will be coordinated with other Medical plans, and dental coverage will be coordinated with other dental plans.
Non-Occupational Injury
A non-occupational injury is an accidental bodily injury that does not:
Arise out of (or in the course of) any work for pay or profit; or
Result in any way from an injury which does.
Is covered under any type of workers' compensation law; and
Is not covered for that injury under such law.
Ronald A. Williams
Chairman, Chief Executive Officer, and President Aetna Life Insurance Company
