Lourdes Health System
Proposed Effective Date: 01-01-2017
™
Aetna Helathfund™ Aetna Choice POS ll - ASC
Salary Band: $42,00 to $69,999
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
FUND FEATURES
HealthFund Amount
$625
$1200
$1200
$1200
Employee
Employee + Spouse
Employee + Child(ren)
Family
Amount contributed to the Fund by the employer
100%
Fund Coinsurance
Percentage at which the Fund will reimburse
The Fund will be used to pay for your member responsibility, including your deductible and coinsurance. Once the
Fund Administration
Employee Termination from Aetna
HealthFund
Fund Rollover
Annual Maximum Rollover
Cumulative Maximum Rollover
Fund Maximum (Cap)
Eligible Fund Expenses
Fund Payment/Assignment
Pro-ration for New Employees
Pro-ration for Family Status Change
PLAN FEATURES
Any remaining HealthFund benefit amount is forfeited (or terminated) when the employee’s Aetna HealthFund
coverage terminates.
Any remaining HealthFund benefit amount at end of plan year is rolled over into next years HealthFund benefit
No maximum rollover applies. All remaining benefits at plan year end rollover.
$6,000
Employee
$12,000
Employee + Spouse
$12,000
Employee + Child(ren)
$12,000
Family
No maximum rollover applies. All remaining benefits at plan year end rollover.
Fund covers same expenses as the medical plan. Expenses above the Reasonable & Customary limit, any plan
Network Providers: Automatic Assignment to provider.
Monthly
Monthly
Lourdes Doctors
(Home Host)
AETNA
PREFERRED CARE
NON-PREFERRED CARE
Individual
Individual
Individual
None
$1,500
$3,000
Family
Family
Family
None
$3,000
$6,000
All covered expense accumulate toward both the preferred and non-preferred Deductible.
Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar year. There is no Individual
Deductible to satisfy within the Family Deductible.
Member Coinsurance
Covered 100%
Covered 80%
Covered 50%
Applies to all expenses unless otherwise stated.
Deductible (per calendar year)
Prepared: 10/15/2015 01:50 PM
Page 1
Lourdes Health System
Proposed Effective Date: 01-01-2016
™
Aetna Helathfund™ Aetna Choice POS ll - ASC
Salary Band: $42,00 to $69,999
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Individual
Individual
$6,000
$6,000
$15,000 Individual
Payment Limit (per calendar year)
$12,000 Family
$12,000 Family
$30,000 Family
All covered expenses including Deductible accumulate toward both the preferred and non-preferred Payment Limit.
Certain member cost sharing elements may not apply toward the Payment Limit.
Only those out-of-pocket expenses resulting from the application of coinsurance percentage and deductibles may be used to satisfy the Payment Limit.
Once Family Payment Limit is met, all family members will be considered as having met their Payment Limit for the remainder of the calendar year. There is no
Individual Payment Limit to satisfy within the Family Payment Limit.
Unlimited
Unlimited
Unlimited
Lifetime Maximum
Unlimited except where otherwise indicated.
Primary Care Physician Selection
Optional
Not applicable
Optional
Certification Requirements Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions,
Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied
separately to each type of expense is $300 per occurrence.
Referral Requirement
None
None
None
Lourdes
Doctors
AETNA
PREVENTIVE CARE
NON-PREFERRED CARE
(Home Host)
PREFERRED CARE
Covered 100%; no deductible
Covered 100%; deductible waived
Covered 100%; deductible waived
Routine Adult Physical Exams/
Immunizations
1 exam per 12 months for members age 18 to age 65; 1 exam per 12 months for adults age 65 and older.
Covered 100%; no deductible
Covered 100%; deductible waived
Covered 100%; deductible waived
Routine Well Child Exams/Immunizations
7 exams in the first 12 months of life, 2 exams in the 13th-24th months of life; 1 exam per 12 months thereafter to age 18.
Covered 100%; no deductible
Covered 100%; deductible waived
Covered 100%; deductible waived
Routine Gynecological Care Exams
Includes Pap smear and related lab fees
Covered 100%; no deductible
Covered 100%; deductible waived
Covered 100%; deductible waived
Routine Mammograms
Covered 100%; no deductible
Covered 100%; deductible waived
Covered 100%; deductible waived
Routine Digital Rectal Exam / Prostatespecific Antigen Test
For covered males age 40 and over.
Covered 100%; no deductible
Covered 100%; deductible waived
Covered 100%; deductible waived
Colorectal Cancer Screening
For all members age 50 and over.
Routine Eye Exams
Covered 100%; no deductible
Covered 100%; deductible waived
Covered 100%; deductible waived
1 routine exam per 24 months.
Routine Hearing Exams
Not Covered
Not Covered
Not Covered
Prepared: 10/15/2015 01:50 PM
Page 2
Lourdes Health System
Proposed Effective Date: 01-01-2017
™
Aetna Helathfund™ Aetna Choice POS ll - ASC
Salary Band: $42,00 to $69,999
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Lourdes Doctors
AETNA
PHYSICIAN SERVICES
NON-PREFERRED CARE
(Home Host)
PREFERRED CARE
Covered 100%; no deductible
Covered 80%; after deductible
Covered 50%; after deductible
Office Visits to PCP
Includes services of an internist, general physician, family practitioner or pediatrician.
Covered 100%; no deductible
Covered 80%; after deductible
Covered 50%; after deductible
Specialist Office Visits
Includes services of an internist, general physician, family practitioner or pediatrician, if the physician is not the member's selected PCP.
Covered 80%; after deductible
Covered 50%; after deductible
Covered 100%; no deductible
Allergy Testing
Allergy Injections
Covered 100%; no deductible
Covered 80%; after deductible
Covered 50%; after deductible
Lourdes Doctors
AETNA
NON-PREFERRED CARE
(Home Host)
PREFERRED CARE
Covered 100%; no deductible
Covered 80%; after deductible
Covered 50%; after deductible
Diagnostic Laboratory and X-ray
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost
sharing
Covered 100%; no deductible
Covered 80%; after deductible
Covered 50%; after deductible
Diagnostic X-ray for Complex Imaging
Services
Lourdes Doctors
AETNA
EMERGENCY MEDICAL CARE
NON-PREFERRED CARE
(Home Host)
PREFERRED CARE
Covered 100% after $75 copay;
Covered 100% after $75 copay
Covered 100% after $25 copay;
Urgent Care Provider
no deductible
dedutible waived
deductible waived
(benefit availability may vary by location)
Not Covered
Not Covered
Not Covered
Non-Urgent Use of Urgent Care Provider
Covered 100% after $100 copay;
Covered 100% after $100 copay;
Covered 100% after $100 copay;
Emergency Room
Copay waived if admitted
no deductible
deductible waived
deductible waived
Non-Emergency care in an Emergency
Not Covered
Not Covered
Not Covered
Room
Not available
Covered 80%; after deductible
Covered 80%; after deductible
Ambulance
Lourdes Doctors
AETNA
HOSPITAL CARE
NON-PREFERRED CARE
(Home Host)
PREFERRED CARE
Covered 100%; no deductible
Covered 80%; after deductible
Covered 50%; after deductible
Inpatient Coverage
DIAGNOSTIC PROCEDURES
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay.
Covered 100%; no deductible
Covered 80%; after deductible
Inpatient Maternity Coverage
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay.
Covered 100%; no deductible
Covered 80%; after deductible
Outpatient Hospital Expenses (including
surgery)
Prepared: 10/15/2015 01:50 PM
Covered 50%; after deductible
Covered 50%; after deductible
Page 3
Lourdes Health System
Proposed Effective Date: 01-01-2016
™
Aetna Helathfund™ Aetna Choice POS ll - ASC
Salary Band: $42,00 to $69,999
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit.
Lourdes Doctors
AETNA
MENTAL HEALTH SERVICES
(Home Host)
PREFERRED CARE
Covered 100%; no deductible
Covered 80%; after deductible
Inpatient
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay.
Not available
Covered 100%; deducibtle waived
Outpatient
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit.
Lourdes Doctors
AETNA
ALCOHOL/DRUG ABUSE SERVICES
(Home Host)
PREFERRED CARE
Covered 100%; no deductible
Covered 80%; after deductible
Inpatient
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay.
Not available
Covered 100%; deducibtle waived
Outpatient
The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit.
Lourdes Doctors
AETNA
OTHER SERVICES
(Home Host)
PREFERRED CARE
Covered 100%; no deductible
Covered 80%; after deductible
Convalescent Facility
Limited to 180 days per calendar year.
The member cost sharing applies to all covered benefits incurring during a member's inpatient stay.
Not available
Covered 100%; deducibtle waived
Home Health Care
Limited to 60 visits per calendar year.
NON-PREFERRED CARE
Covered 50%; after deductible
Covered 50%; after deductible
NON-PREFERRED CARE
Covered 50%; after deductible
Covered 50%; after deductible
NON-PREFERRED CARE
Covered 50%; after deductible
Covered 50%; after deductible
Not available
Covered 100%; deducibtle waived
Covered 50%; after deductible
Hospice Care - Inpatient
Unlimited visits.
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
Not available
Covered 100%; deducibtle waived
Covered 50%; after deductible
Hospice Care - Outpatient
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit
Not Covered
Not Covered
Not Covered
Private Duty Nursing - Outpatient (Limited to
70 eight hour shifts per calendar year)
Each period of private duty nursing of up to 8 hours will be deemed to be one private duty nursing shift.
Each visiting nurse care or private duty nursing care shift of 4 hours or less counts as one home health visit. Each such shift of over 4 hours and up to 8 hours counts
as two home health care visits.
Covered 100%; no deductible
Covered 80%; after deductible
Covered 50%; after deductible
Outpatient Short-Term Rehabilitation
Include Speech, Physical, and Occupational Therapy, limited to 60 visits per calendar year.
Covered 80%; after deductible
Covered 50%; after deductible
Not Available
Spinal Manipulation Therapy
Limited to 60 visits per calendar year
Not Available
Covered 80%; after deductible
Covered 50%; after deductible
Durable Medical Equipment
Prepared: 10/15/2015 01:50 PM
Page 4
Lourdes Health System
Proposed Effective Date: 01-01-2017
™
Aetna Helathfund™ Aetna Choice POS ll - ASC
Salary Band: $42,00 to $69,999
Diabetic Supplies
Contraceptive drugs and devices not
obtainable at a pharmacy (includes coverage
for contraceptive visits)
Vision Eyewear
Transplants
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Covered same as any other medical
expense.
Not Covered
Not Covered
Covered same as any other medical
expense.
Not Covered
$100 reimbursement combined maximum for all covered eyeglass lenses, frames, and contact lenses
Covered 80%; after deductible
Covered 50%; after deductible NonCovered 100%; no deductible
Preferred coverage is provided at an Preferred coverage is provided at a
Member cost sharing is based on the Member cost sharing is based on the Member cost sharing is based on the
Mouth, Jaws and Teeth
type of service performed and the
type of service performed and the
type of service performed and the
(oral surgery procedures, whether medical or
place of service where it is rendered
place of service where it is rendered
place of service where it is rendered
dental in nature)
Lourdes Doctors
AETNA
FAMILY PLANNING
NON-PREFERRED CARE
(Home Host)
PREFERRED CARE
Infertility Treatment
Member cost sharing is based on the Member cost sharing is based on the Member cost sharing is based on the
type of service performed and the
type of service performed and the
type of service performed and the
place of service where it is rendered
place of service where it is rendered
place of service where it is rendered
Diagnosis and treatment of the underlying medical condition.
Comprehensive Infertility Services
Advanced Reproductive Technology (ART)
Female Voluntary Sterilization
Including tubal ligation, abdominal sterilization,
vaginal sterilization, essure, and laparoscopy.
Excludes reversals.
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not covered
Male Voluntary Sterilization
Including vasectomy
Not Covered
Not Covered
Not Covered
GENERAL PROVISIONS
Dependents Eligibility
Spouse, children from birth to age 26
This plan does not cover all health care expenses and includes 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, your plan documents
may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer.
Prepared: 10/15/2015 01:50 PM
Page 5
Lourdes Health System
Proposed Effective Date: 01-01-2016
™
Aetna Helathfund™ Aetna Choice POS ll - ASC
Salary Band: $42,00 to $69,999
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Charges related to any eye surgery mainly to
correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care; Dental care and X-rays; Donor egg retrieval; Experimental and investigational
procedures; Hearing aids; Immunizations for travel or work; 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 your plan documents; Nonmedically necessary services
or supplies; Orthotics; Over-the-counter medications and supplies; Reversal of sterilization; Services for the treatment of sexual dysfunction or inadequacies,
including therapy, supplies, or counseling; and special duty nursing.
This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or
programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan
documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitation
relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent contractors in private practice and are
neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be
guaranteed, and provider network composition is subject to change without notice.
Some benefits are subject to limitations or visit maximums. Certain services require precertification, or prior approval of coverage. Failure to precertify for these
services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient
hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the
Member’s preferred provider is coordinating care, the preferred provider will obtain the precertification. When the member utilizes a non-preferred provider, Member
must obtain the precertification. Precertification requirements may vary. Depending on the plan selected, new prescription drugs not yet reviewed by our medication
review committee are either available under plans with an open formulary or excluded from coverage unless a medical exception is obtained under plans that use a
closed formulary.
They may also be subject to precertification or step-therapy. Non-prescription drugs and drugs in the Limitations and Exclusions section of the plan documents
(received after open enrollment) are not covered, and medical exceptions are not available for them. While this information is believed to be accurate as of the print
date, it is subject to change.
Plans are provided by Aetna Life Insurance Company.
Prepared: 10/15/2015 01:50 PM
Page 6