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N 2����' N AETNA LIFE INSURANCE COMPANY
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62015 MEDICARE ADVANTAGE PPO
GROUP AGREEMENT COVER SHEET
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Contract Holder: City Of Fort Worth
Contract Holder Number: 411868
017;063-108;110,111,113
TXO 1,AK3 0,AR31,AZO 1,CAO 1,
CA05,FLO 1,171,02,171,03,171,05,171,3 l,GAO 1,GA31,I
L02,IN32,KS0l,KS3 O,LA3 O,MI31,MN30,M003,M
030,MO3 3,MS3 O,MS31,NC01,NE01,NH01,
NM3 0,OHO 1,OH02,OH 03,OK02,OK3 0,O R3 0,
PAO 1,SC30,TN31,TX02,TX03,TX04,TX05,TX31,
TX32,TX3 7,TX3 8,VA32,WA3 0,WY3 0
PPO Plan: MEDICARE(C04)ESA PPO Benefits Package
with Medicare Prescription Drug benefit
Effective Date: 12:01 a.m. on January 1,2015
Term of Group Agreement: The Initial Term shall be: From January 1, 2015
through December 31, 2015
Thereafter, Subsequent Terms shall be: From
January 1st through December 31st
Premium Due Dates: The Group Agreement Effective Date and the 1st
day of each succeeding calendar month.
Plan Premium Rates: Please refer to the rate/financial exhibit and/or final
renewal communication (and any amendments
made thereto) issued by Aetna in connection with
this Group Agreement and attached hereto as
Exhibit B ("Rate Documents")for applicable rates.
Right to Audit: Aetna agrees that Contract Holder shall, until the
expiration of one (1) year .after final payment
under this agreement, have access to and the right
to examine any directly pertinent books,
documents, papers, and records regarding
Contract Holder's premium, participant census
data, and billing under this Agreement. Aetna
agrees that Contract Holder shall have access
OFFICIAL RECORD
ME PPO GA(Y2015) 1 CITY SECRETARY GRP GAPPO 2015
FT.WORTH, TX
during normal working hours to all necessary
Aetna facilities and shall be provided adequate
and appropriate workspace in order to conduct
audits in compliance with this provision. Contract
Holder shall give Aetna reasonable advance notice
of intended audits.
Term of Rates: From January 1, 2015 to December 31, 2015.
These rates are subject to adjustments based on final
regulatory determinations.
Governing Federal law and, to the extent not preempted, the
laws of the State of Texas.
Notice Address for Aetna 1425 Union Meeting Road
Blue Bell,PA 19422
and to Contract Holder at: City Of Fort Worth
Assistant City Manager for Human Resources
With copy to
Human Resources Department
Attn—Benefits
1000 Throckmorton
Fort Worth TX 76102
NOTICE: The parties shall attempt in good faith to resolve any dispute arising out of or relating
to this Agreement promptly by negotiation between executives who have authority to settle the
controversy and who are at a higher level of management than the persons with direct
responsibility for administration of the contract. Any party may give the other party written
notice of any dispute not resolved in the normal course of business, including the prescribed
period to cure alleged breaches of contract. Within (15) days after delivery of the notice, the
receiving party shall submit to the other a written response. The notice and the response shall
include (a) a statement of each party's position and a summary of arguments supporting that
position, and (b) the name and title of the executive who will represent that party and of any
other person who will accompany the executive. Within (30) days after delivery of the disputing
party's notice, the executives of both parties shall meet at a mutually convenient time and place,
and thereafter as often as they reasonably deem necessary, to attempt to resolve the dispute. All
reasonable requests for information made by one party to the other will be honored. All
negotiations pursuant to this provision are confidential and shall be treated as compromise and
settlement negotiations for purposes of applicable rules of evidence. If the dispute is not resolved
by negotiation between executives, the patties shall endeavor to settle the dispute by mediation
ME PPO GA(Y2015) 2 GRP GAPPO 2015
under the then current CPR/AAA Mediation Procedure. Unless otherwise agreed,the parties will
select a mediator from CPR/AAA Panels of Mediators.
For further information, see section titled "Dispute Resolution" of this Group Agreement, and
the section titled"Notice on Binding Arbitration"in the Evidence of Coverage(EOC).
The signatures below are evidence of Aetna's and Contract Holder's acceptance of the Contract
Holder's Group Application on the terms hereof and constitutes execution of the Group
Agreement(s) attached hereto on behalf of Aetna and Contrllact,Holder.
Signed this V 0 day of ,Q IlYV , 201bo
AETNA LIFE INSURANCE COMPANY
By:
Gregory S. Martino
Vice President
CONTRACT HOLDER: APPROVED AS TO
LEGALITY:
By: poo'se
Title: S S`� • 04-4 � f' A ITY ATTORNE
Contract Holder Name: City of Fort Worth jq C L�
Contract Holder Number: 411868
Contract Holder Locations: 017;063-108;110,111,113
Contract Holder Service Areas: TXOI,AK30,AR31,AZO1,CAO1,
CA05,FLO 1,FL02,FL03,FL05,FL31,GAO 1,GA31,lL02,IN32,KS01,KS30,LA30,M131,MN30,
M003,MO30,MO33,MS30,MS31,NCO 1,NEO 1,NHO 1,NM30,OHO 1,OH02,OH03,OK02,
OK30,OR30,PAO1,SC30,TN31,TX02,TX03,TX04,TX05,TX31,TX32,TX37,TX38,VA OF Fps
WA30,WY30
Contract Holder Group Agreement Effective Date: January 1, 2015
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OFFICIAL RECORD olcaaid Ponly secretary
CITY SECRETARY
FT.WORTH,TX
ME PPO GA(Y2015) 3 GRP GAPPO 2015
AETNA LIFE INSURANCE COMPANY
(TEXAS)
MEDICARE ADVANTAGE PPO GROUP AGREEMENT
This Group Agreement is entered into by and between Aetna Life Insurance Company and the
Contract Holder specified in the attached Cover Sheet. This Group Agreement shall be effective
on the Effective Date specified in the Cover Sheet, and shall continue in force until terminated as
provided herein.
In consideration of the mutual promises hereunder and the payment of Premiums and fees when
due, We will provide coverage for benefits in accordance with the terms, conditions, limitations
and exclusions set forth in this Group Agreement.
SECTION 1. DEFINITIONS
1.1 "Aetna Medicare PPO plan" or "Plan" means the Aetna MedicaresM Plan (PPO),
including Medicare prescription drug benefits, which is a Medicare Advantage Preferred
Provider Organization Plan offered by Aetna to Contract Holder under this Group
Agreement.
1.2 The terms "Aetna", "Us", "We" or "Our" mean Aetna Life Insurance Company, an
affiliate ora th rd`P6] y v6ndor'.
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3 �
1.3 "CMS" means the Centers for Medicare and Medicaid Set-vices.
1.4 '``C "the contract between Aetna and CMS under which Aetna offers
the Plan.
1.5 The terms "Contract Holder", "Effective Date", "Initial Term", "Premium Due Date" and
"Subsequent Terms" will have the meaning set forth in the attached Cover Sheet. If any
of such terms are undefined in the Cover Sheet, such undefined terms shall have the
following meaning:
• "Effective Date" means the date health coverage under this Group Agreement
commences for the Contract Holder.
"Initial Term" is the period following the Effective Date as indicated on the Cover
Sheet.
• "Premium Due Date(s)" is the Effective Date and each monthly anniversary of the
Effective Date.
• "Subsequent Term(s)" means the periods following the Initial Term as indicated
on the Cover Sheet.
ME PPO GA(Y2015) 1 GRP GAPPO 2015
1.6 "Covered Benefits" is a general term we use to mean all of the health care services and
supplies, including Medicare prescription drug benefits, that are covered by Our Plan,
subject to all of the terms and conditions of the EOC and Schedule of
Copayments/Coinsurance and this Group Agreement.
1.7 "EOC" means the Evidence of Coverage, which is a document outlining coverage for
Members under the Plan that is issued pursuant to this Group Agreement, and includes
the Schedule of Copayments/Coinsurance and any riders or amendments.
1.8 `ERISA"means the Employee Retirement Income Security Act of 1974, as amended.
1.9 "Grace Period" is defined in the Premiums and Fees section below.
1.10 "Group Agreement" means the Contract Holder's Group Application, this document, the
attached Cover Sheet; the EOC and Schedule of Copayments/Coinsurance issued
hereunder and attached hereto as Exhibit A; the Rate Documents issued by Us in
connection with this Group Agreement and attached hereto as Exhibit B; the Plan Design
and Benefit Summary attached hereto as Exhibit C; and any riders, amendments, inserts
or attachments issued pursuant hereto, all of which are incorporated into or incorporated
by reference into and made a part of this Group Agreement.
1.11 "Mandates" means applicable laws, regulations and government requirements in effect
during the Term of this Group Agreement including, without limitation, applicable
Medicare laws, regulations and CMS requirements.
1.12 "Member" is a Medicare beneficiary who: (1) has enrolled in Our Plan and whose
enrollment in the Plan has been confirmed by CMS, and (2) is eligible to receive
coverage under the Plan, subject to the terms and conditions of the EOC and Schedule of
Copayments/Coinsurance and this Group Agreement.
1.13 "Party, Parties"means Aetna and Contract Holder.
1.14 "Premium(s)" is defined in the Premiums and Fees section below.
1.15 "Renewal Date" means the fust day following the end of the Initial Term or any
Subsequent Term.
1.16 "Term" means the Initial Term or any Subsequent Term set forth in the Cover Sheet to
this Group Agreement.
1.17 Capitalized terms not defined in this Group Agreement shall have the meaning set forth
in the EOC. In the event of a conflict between the terms of this Group Agreement and
the terms of the EOC,the terms of this Group Agreement shall prevail.
ME PPO GA(Y2015) 2 GRP GAPPO 2015
SECTION 2. COVERAGE
2.1 Covered Benefits. We will provide coverage for Covered Benefits to Members subject
to the terms and conditions of this Group Agreement. Coverage will be provided in
accordance with the reasonable exercise of Our business judgment, consistent with
Mandates. Members covered under this Group Agreement are subject to all of the
conditions and provisions contained herein and in the incorporated documents.
2.2 Policies and Procedures. We have the right to adopt reasonable policies, procedures,
rules, and interpretations of this Group Agreement and the EOC in order to promote
orderly and efficient administration of the Plan and/or comply with Mandates ("Policies
and Procedures"). Aetna will provide Contract Holder with sixty (60) days advanced
written notice, unless a shorter period of time is required for Aetna to comply with
Mandates, if Contract Holder must comply with any such Policies and Procedures.
SECTION 3. PREMIUMS AND FEES
3.1 Premiums. Contract Holder shall pay Us on or before each Premium Due Date a
monthly premium (the "Premium") determined in accordance with the Premium rates and
the manner of calculating Premiums as set forth in Exhibit B. Premium rates and the
manner of calculating Premiums may be adjusted in accordance with the Changes in
Premium and Membership Adjustments sections below. Premiums are subject to
adjustment, if any, for partial month participation as specified in the Membership
Adjustments section below. Membership as of each Premium Due Date will be
determined by Us in accordance with Our Member records. A check does not constitute
payment until it is honored by a bank. We may return a check issued against insufficient
funds without making a second deposit attempt. We may accept a partial payment of
Premium without waiving Our right to collect the entire amount due.
This Group Agreement is subject to the annual renewal of the Aetna's CMS Contract.
Covered Benefits and/or Premiums are also subject to change at the beginning of a Term
of this Group Agreement. Increases in Member Premiums and/or decreases in Covered
Benefits are only permitted at the beginning of a Term of this Group Agreement. Should
CMS terminate Our CMS Contract or should We decide not to renew Our CMS Contract,
Members shall be given notice of such termination in accordance with the Aetna
Medicare Advantage EOC and any Mandates.
3.2 Fees. In addition to the Premium, We may charge the following fees, if such fees are
agreed to in writing by the parties:
• An installation fee may be charged upon initial installation of coverage or any
significant change in installation (e.g., a significant change in the number of
Members or a change in the method of reporting Member eligibility to Us). A fee
may also be charged upon initial installation for any custom Plan set-ups.
ME PPO GA(Y2015) 3 GRP GAPPO 2015
• A billing fee may be added to each monthly Premium bill. The billing fee may
include a fee for the recovery of any surcharges for amounts paid through credit
card, debit card or other similar means.
• A reinstatement fee as set forth in the Effect of Termination section below.
3.3 Past Due Premiums and Fees. If a Premium payment or any Fees are not paid in full by
Contract Holder on or before the Premium Due Date, a late payment charge in
accordance with Subchapter B of Chapter 2251 of the Government Code . If all
Premiums and Fees are not received within 30 days following the Premium Due Date (the
"Grace Period"), Contract Holder's failure to make such payment will constitute a breach
of this Group Agreement and this Group Agreement will be automatically terminated
pursuant to the Termination by Us section hereof.
If the Group Agreement terminates for any reason, Contract Holder will continue to be
held liable for all Premiums and Fees due and unpaid before the termination, including,
but not limited to, Premium payments for any period of time the Group Agreement is in
force during the Grace Period. Members shall also remain liable for Member cost
sharing and other required contributions to coverage for any period of time the Group
Agreement is in force during the Grace Period.
3.4 Chances in Premium. We may also adjust the Premium rates and/or the manner of
calculating Premiums upon prior written notice to Contract Holder, provided that such
prior written notice is provided as soon as reasonably possible, but no later than 120
days prior to the effective date and no such adjustment will be made during the Initial
Term except as provided in the Rate Documents or to reflect changes in Mandates or a
judicial decision having a material impact on the cost of providing Covered Benefits to
Members.
3.5 Membership Adjustments. We may, at Our discretion, make retroactive adjustments to
the Contract Holder's billings for the termination of Members not posted to previous
billings. However, Contract Holder may only receive a maximum of 2 calendar months
credit for Member terminations that occurred more than 30 days before the date Contract
Holder notified Us of the termination. We may reduce any such credits by the amount of
any payments We may have made on behalf of such Members (including capitation
payments and other claim payments) before We were informed their coverage had been
terminated. Retroactive additions will be made at Our discretion based upon eligibility
guidelines, as set forth in the EOC, and are subject to the payment of all applicable
Premiums.
3.6 Uniform Premiums and Low Income Subsidy. Contract Holder shall comply with the
following conditions with respect to any subsidization of that portion of Premiums paid
by Contract Holder for the Medicare Prescription Drug benefit("MA-PD Premium") and
any required MA-PD Premium contribution by the Member:
ME PPO GA(Y2015) 4 GRP GAPPO 2015
• Contract Holder may subsidize different amounts of MA-PD Premium for
different classes of Members and their dependents, provided such classes are
reasonable and based on objective business criteria, such as years of service,
business location, job category, and nature of compensation (e.g., salaried vs.
hourly). Classes of Members and their dependents cannot be based on eligibility
for the Low Income Subsidy("LIS")provided by CMS for certain individuals.
• MA-PD Premium contribution levels cannot vary for Members within a given
class.
• Direct subsidy payments from CMS to Aetna must be passed through to reduce
the amount of any required MA-PD Premium payment by the Member ("Member
Contribution") so the Member in no event shall be required to pay more than the
sum of. a) the standard Medicare Part D premium, net of the direct subsidy
payment from CMS, and b) one hundred percent (100%) for any supplemental
coverage selected by the Member.
Contract Holder shall comply with the following conditions with respect to any LIS
payment received from CMS for any LIS-eligible Member:
• Any monthly LIS payment received from CMS for an LIS-eligible Member shall
be used to reduce any Member Contribution. Any remainder may then be used to
reduce the amount of the Contract Holder's MA-PD Premium contribution.
• If the LIS payment for any LIS-eligible Member is less than the Member
Contribution required by such individual (including the Member Contribution for
supplemental benefits, if any), Contract Holder shall communicate with the LIS-
eligible Member about the cost of remaining enrolled in Contract Holder's Plan
versus obtaining coverage as an individual under another Medicare Part D
Prescription Drug plan.
SECTION 4. ENROLLMENT
4.1 Open Enrollment. Contract Holder will offer enrollment in the Aetna Medicare PPO
plan:
• at least once during the term of this Group Agreement during Contract Holder's
annual open enrollment period ("Open Enrollment Period"); and
• within 31 days from the date an individual or any dependent becomes eligible to
receive coverage under the Plan.
Eligible individuals and dependents who are not enrolled in the Plan within the Open
Enrollment Period or 31 days of becoming eligible may be enrolled during any
subsequent Open Enrollment Period. Coverage under the Plan will not become effective
until confirmed by Us. Contract Holder agrees to hold the Open Enrollment Period
consistent with the open enrollment period applicable to any other group health benefit
ME PPO GA(Y2015) 5 GRP_GAPPO 2015
plan being offered by the Contract Holder and in compliance with Mandates. The
Contract Holder shall permit Our representatives to meet with eligible individuals and
dependents during the Open Enrollment Period unless the parties agree upon an alternate
enrollment procedure.
4.2 EliLlibility. Actively working employees and their dependents are not permitted to enroll
in the Plan, unless Contract Holder employs between two and nineteen (2-19) employees.
The number of eligible individuals and eligible dependents and composition of the Plan,
the identity and status of Contract Holder, the eligibility requirements used to determine
membership in the Plan, and the participation and contribution standards applicable to the
Plan which exist at the Effective Date of this Group Agreement are material to the
execution and continuation of this Group Agreement by Us. The Contract Holder shall
not, during the Term of this Group Agreement, modify the Open Enrollment Period or
any other eligibility requirements as described in the EOC and on the Schedule of
Copayments/Coinsurance, for the purposes of enrolling Contract Holder's eligible
individuals and eligible dependents under this Group Agreement, unless We agree to the
modification in writing.
SECTION 5. RESPONSIBILITIES OF THE CONTRACT HOLDER
In addition to other obligations set forth in this Group Agreement, Contract Holder agrees to:
5.1 (A) Records. Furnish to Us, on a monthly basis (or as otherwise required), on Our form
(or such other form as We may reasonably approve) by facsimile (or such other means as
We may reasonably approve), such information as We may reasonably require to
administer this Group Agreement. This includes, but is not limited to, information
needed to enroll Members of the Contract Holder, process terminations, and effect
changes in family status and transfer of employment of Members.
Contract Holder certifies, based on best knowledge, information and belief, that all
enrollment and eligibility information that has been or will be supplied to Us is accurate,,
complete and truthful. Contract Holder acknowledges that We can and will rely on such
enrollment and eligibility information in determining whether an individual is eligible for
Covered Benefits under this Group Agreement. To the extent such information is
supplied to Us by Contract Holder (in electronic or hard copy format), Contract Holder
agrees to:
• Obtain from all Members a "Disclosure of Healthcare Information" authorization
in the form currently being used by Us in the enrollment process (or such other
form as We may reasonably approve).
• Maintain a reasonably complete record of such information (in electronic or hard
copy format, including evidence of coverage elections, evidence of eligibility,
changes to such elections and terminations) for at least ten (10)years and to make
such information available to Us upon request, as required under this Section 5.
ME PPO GA(Y2015) 6 GRP GAPPO 2015
We will not be liable to Members for the fulfillment of any obligation prior to
information being received in a form satisfactory to Us. Contract Holder must notify Us
of the date in which a Member's employment/eligibility ceases for the purpose of
termination of coverage under this Group Agreement.
(B) Maintenance of Information and Records. Contract Holder agrees to maintain
Information and Records (as those terms are defined in the Access to Information and
Records Section below) in a current, detailed, organized and comprehensive manner and
in accordance with Mandates, and to maintain such Information and Records for the
longer of. (i) a period of ten (10) years from the end of the final contract period of any
government contract of Aetna to offer an Aetna Medicare PPO plan, (ii) the date the U.S.
Department of Health and Human Services, the Comptroller General or their designees
complete an audit, or (iii) the period required by Mandates. This Provision shall survive
the termination of this Group Agreement, regardless of the cause of the termination.
(C) Access to Information and Records. Contract Holder agrees to provide Us and
federal, state and local governmental authorities having jurisdiction, directly or through
their designated agents (collectively "Government Officials"), upon request, access to all
books, records and other papers, documents, materials and other information (including,
but not limited to, contracts and financial records),whether in paper or electronic format,
relating to the arrangement described in this Group Agreement ("Information and
Records"). Contract Holder agrees to provide Aetna and Government Officials with
access to Information and Records for as long as it is maintained as provided in
"Information and Records" Section above. Contract Holder agrees to supply copies of
Information and Records within fourteen (14) calendar days of Contract Holder's receipt
of the request, where practicable, and in no event later than the date required by
Mandates. This provision shall survive termination of this Group Agreement, regardless
of the cause of termination.
5.2 Forms. If agreed to by both Parties, distribute materials to Aetna Members regarding
enrollment, Plan features, including Covered Benefits and exclusions and limitations of
coverage, as required under Mandates. Contract Holder shall, within no fewer than 10
days of receipt from an eligible individual, forward all completed enrollment information
and other required information to Us.
5.3 Policies and Procedures, Compliance Verification. Comply with all Policies and
Procedures, as described in Section 2.3 of this Group Agreement. Aetna will provide
Contract Holder with sixty (60) days advanced written notice, unless a shorter period of
time is required for Aetna to comply with Mandates, if Contract Holder must comply
with any such Policies and Procedures. Contract Holder shall, upon request, provide a
certification to Aetna of its compliance with Mandates applicable to Contract Holder
under this Group Agreement
5.4 Written Notice to Members. Contract Holder will distribute to Members any written
notice that We provide to Contract Holder for distribution to Members describing any
changes made to Covered Benefits at least thirty (30) days prior to the effective date of
ME PPO GA(Y2015) 7 GRP GAPPO 2015
such change(s) or as required under Mandates, provided that such obligation shall be
contingent on timely receipt of notices from Us. Contract Holder will provide Members
with any written notice required under Mandates or Policies and Procedures. The written
notices described in this Section are hereinafter collectively referred to as the "Written
Notices". If Contract Holder receives the Written Notices from US in a timely manner
but does not distribute Written Notices to Members as required under this Section 5.4,
Contract Holder will be liable to the extent allowed by law for payment of all Premiums
or other costs incurred by Aetna as a result of Contract Holder's failure to distribute the
Written Notices. If Contract Holder does not distribute the Written Notices as required
under this Section and Aetna is not responsible for the failure or delay, Aetna may, in its
discretion, distribute such Written Notices to Members, and Contract Holder shall
reimburse Aetna for any expenses incurred by Aetna in connection with such distribution.
Contract Holder acknowledges that CMS requires that all Members receive from Aetna a
combined Annual Notice of Change (ANOC) and EOC no later than the sooner of: (1)
fifteen (15) days prior to the Open Enrollment Period, (2) September 30th of each
calendar year, or(3) such shorter timeframe required under Mandates.
5.5 Member Plan Materials. Contract Holder shall assure that any Member Plan materials
that have not been approved by CMS comply with the following alternative disclosure
standards: "ERISA" or any alternative disclosure standards applicable to state or local
entities that provide retiree benefits.
5.6 ERISA Requirements. Maintain responsibility for making reports and disclosures
required by "ERISA", including the creation, distribution and final content of summary
plan descriptions, summary of material modifications and summary annual reports, unless
Contract Holder's Plan is specifically exempt thereunder.
5.7 Enrollment& Disenrollment Transactions.
(A) Generally, To the extent that Contract Holder directly accepts enrollment and/or
disenrollment requests from Members that Contract Holder forwards to Aetna for
processing and submission to CMS, Contract Holder agrees to comply with all Mandates
that relate to the handling and processing of enrollment and disenrollment requests that
apply to the Plan ("Enrollment/Disenrollment Requirements"), including, without
limitation, all Enrollment/Disenrollment Requirements that relate to the timeframes that
apply to handling, processing and submission of enrollment and disenrollment requests
for the Plan. Contract Holder agrees to forward enrollment and disenrollment forms
completed by Members to Aetna no later than ninety (90) days after the Member's
coverage effective date. Contract Holder acknowledges that if there is a delay between
the time a Member submits an enrollment/disenrollment request to Contract Holder and
when the enrollment/disenrollment request is received by Aetna, the
enrollment/disenrollment transaction may not be processed by CMS, unless Aetna
requests and CMS approves a retroactive enrollment/disenrollment transaction for the
Member. Contract Holder further acknowledges that Aetna, in its sole discretion and
judgment, will determine whether to submit retroactive enrollment and disenrollment
ME PPO GA(Y2015) 8 GRP GAPPO 2015
transaction requests to CMS, and will make such determinations in accordance with
Mandates.
Contract Holder acknowledges that, per Enrol lment/Disenrollment Requirements, the
effective date of enrollments and disenrollments in the Plan cannot be earlier than the
date the enrollment or disenrollment request was completed by a Member. If approved
by CMS, the effective date of an enrollment or disenrollment may be retroactive up to,
but may not exceed, ninety(90) days from the date that Aetna received the enrollment or
disenrollment request from Contract Holder, and the enrollment or disenrollment form
must be completed and signed by the Member prior to the requested enrollment or
disenrollment effective date.
Contract Holder acknowledges that CMS does not perinit Contract Holder to
retroactively terminate a Member's coverage under the Plan if the Member no longer
meets Contract Holder's eligibility criteria to remain enrolled in the Plan. To meet these
CMS requirements, Contract Holder agrees to provide Aetna with written notice if
Contract Holder chooses to terminate a Member's coverage under the Plan based on loss
of eligibility, and Contract Holder acknowledges that the Member's coverage termination
effective date will be determined in accordance with Mandates.
All of the requirements described in this Section 5.7 also apply equally to any third party
administrator or other entity retained by Contract Holder to accept and/or process
enrollment/disenrollment requests for the Plan from Members on Contract Holder's
behalf.
(B) Notice to Members. CMS requires that Aetna provide written notice to all Members
confirming their enrollment in or disenrollment from the Plan from Aetna. The written
notice sent by Aetna confirming a Member's disenrollment from the Plan must describe
how the Member can contact Medicare for information about other Medicare Advantage
or Medicare Prescription Drug plan options that may be available to the Member.
If Contract Holder elects to change the Plan coverage offered to a Member or terminate a
Member's coverage under the Plan, the Contract Holder must provide written notice to
the Member at least twenty-one (21) calendar days prior to the effective date of the
change in the Member's coverage or disenrollment from the Plan, as applicable. This
written notice to Members must include a description of how the Member can contact
Medicare to obtain information regarding other Medicare Advantage plan or Medicare
Prescription Drug plan options that may be available to the Member.
We reserve the right to notify Members of the involuntary termination of their coverage
under this Group Agreement for any reason.
(C) Electronic Enrollment and Disenrollment. To the extent that the Contract Holder
has elected to electronically enroll eligible employees or retirees and their eligible
dependents ("Eligible Party" or Eligible Parties") in the Aetna Medicare PPO plan
("Enroll" or `Enrollment") and to electronically terminate the coverage of Members
ME PPO GA(Y2015) 9 GRP GAPPO 2015
under the Aetna Medicare PPO plan ("Disenroll" or "Disenrollment"), and Aetna has
agreed to accept Enrollment and Disenrollment information from Contract Holder
through a roster and electronically process such Enrollments and Disenrollments,
Contract Holder must meet certain administrative and legal requirements set forth in this
section of this Group Agreement.
Aetna will electronically Enroll Eligible Parties who have elected the Plan coverage
("Electronic Enrollment") and electronically Disenroll Members from the Plan
("Electronic Disenrollment"), provided Contract Holder meets the following
requirements:
• Uses Aetna Enrollment and Disenrollment forms approved by CMS for Electronic
Enrollments and Disenrollments ("Aetna Enrollment and Disenrollment Forms").
As permitted under Mandates and this Group Agreement, Contract Holder may
permit Eligible Parties to electronically submit an election form to enroll in a Plan
("Online Enrollment Form")to Contract Holder("Online Election Process").
• Confirms that all Aetna Enrollment and Disenrollment Forms and Online
Enrollment Forms contain all data required by CMS, prior to requesting that
Aetna process any Electronic Enrollments or Disenrollments.
• Maintains and provides access to all original Aetna Enrollment and Disenrollment
Forms and Online Enrollment Forms completed by Eligible Parties and Members
in accordance with the Records section of this Group Agreement and all
Mandates.
• Submits Electronic Enrollment and Disenrollments to Aetna timely and accurately
in accordance with Mandates, Aetna policies and procedures, and this Group
Agreement.
• Submits to Aetna all data elements that are required by CMS and Aetna with
respect to each Electronic Enrollment and Disenrollment, including, but not
limited to,the following data elements:
• Name
• Permanent Address
• Medicare Claim Number(1-ICN)
• End Stage Renal Disease (ESRD)
• Gender
• Date of Birth
• Plan Selection
• Provider Selection (if applicable)
• Group Number
• Class Code
• Plan ID
• Effective Date
Contract Holder agrees to be bound by all Mandates applicable to Electronic Enrollment
and Disenrollment. If Aetna determines, in its sole discretion and judgment, that the
Electronic Enrollment or Disenrollment information provided by Contract Holder is
incomplete,the Electronic Enrollment or Disenrollment will not be processed.
ME PPO GA(Y2015) 10 GRP GAPPO 2015
Electronic Enrollments deemed by Aetna to be complete will be processed by Aetna for
the first of the month following receipt of the electronic file from Contract Holder.
Electronic Enrollments may be processed 90 days retroactively from the current CMS
effective cycle date when the following conditions apply:
• The requested effective date is indicated on the Aetna Enrollment Form or Online
Enrollment Form completed by an Eligible Party, and on the electronic file
transmitted by Contract Holder to Aetna; and
• The Aetna Enrollment Form is signed or the Online Enrollment Form is received
by an Eligible Party prior to the requested effective date or prior to the date the
Aetna Enrollment Form or Online Enrollment Form was completed by the
Eligible Party.
Electronic Disenrollments deemed by Aetna to be complete will be processed by Aetna
for the first of the month following receipt of the electronic file. Aetna will only process
Electronic Disenrollments where an Eligible Party has voluntarily elected to Disenroll
from a Plan by submitting a fully completed Aetna Disenrollment Form to Contract
Holder. Aetna will not process Electronic Disenrollments where Contract Holder has
elected to Disenroll an Eligible Party from a Plan due to Eligible Party's failure to pay
Plan premium or any other basis.
Contract Holder will produce, at Aetna's request, the original copy of any Aetna
Enrollment or Disenrollment Form or record of the Online Enrollment Form completed
by an Eligible Party.
Contract Holder agrees that it will transmit to Aetna only that information which is
reflected on an Aetna Enrollment or Disenrollment Form or Online Enrollment Form that
is completed and signed, as required, by an Eligible Party.
Contract Holder agrees to obtain from Eligible Parties information, including
authorizations, reasonably necessary for Aetna to perform its obligations under the
arrangements set forth in this Group Agreement.
Aetna shall not be responsible for any costs, expenses, claims or judgements, including
attorney's fees resulting from Contract Holder's failure to comply with the terms of these
provisions.
SECTION 6. TERMINATION
6.1 Termination by Contract Holder. The Parties acknowledge the CMS requirement that
Aetna provide Members with a minimum of 30 days' advance written notice prior to
termination of their coverage under the Plan. To allow Aetna to comply with this CMS
requirement, this Group Agreement may be terminated by Contract Holder by providing
Us with a minimum of 60 days prior written notice ('Notice of Termination"). The
Notice of Termination shall specify the effective date of such termination, which shall be
ME PPO GA(Y2015) 11 GRP GAPPO 2015
on the 1St day of a calendar month and may not be less than 60 days from the date of the
notice, and including the following information: Contract Holder's name, Contract
Holder's Group Number, Service Area(s) (if Contract Holder elects to terminate the Plan
in some, but not all, Service Areas covered under this Group Agreement), Plan name, and
the effective date of termination of the Group Agreement.
6.2 Renewal of Group Agreement. This Group Agreement is renewable annually, unless
Aetna will no longer offer any Aetna Medicare PPO plan in any Service Areas covered
under this Group Agreement, because: (1) CMS terminates or otherwise non-renews the
Aetna's CMS Contract, or (2) We terminate Our CMS Contract or reduce the service
areas referenced in Our CMS Contract.
6.3 Termination by Us. This Group Agreement will terminate as of the last day of the
Grace Period if the Premium remains unpaid at the end of the Grace Period.
This Group Agreement may also be terminated by Us as follows:
• Immediately upon notice to Contract Holder if Contract Holder has performed
any act or practice that constitutes fraud or made any intentional
misrepresentation of a material fact relevant to the coverage provided under this
Group Agreement;
• Immediately upon notice to Contract Holder if Contract Holder no longer has any
Member under the Plan who resides in the Service Area;
• Upon 30 days written notice to Contract Holder if Contract Holder (i) breaches a
provision of this Group Agreement and such breach remains uncured at the end of
the notice period; (ii) fails to meet Our contribution or participation requirements
applicable to this Group Agreement that are set forth in the Rate Documents; (iii)
fails to provide the certification required under Section 5.3 of this Group
Agreement within fourteen (14) business days of Our request, unless a shorter
period of time is required for Aetna to comply with Mandates; (iv) provides
written notice to Members stating that coverage under this Group Agreement will
no longer be provided to Members; (v) changes its eligibility or participation
requirements without Our consent or (vi) ceases to meet any Mandates applicable
to offering the Plan to Contract Holder, including those Mandates described in
Section 9.21 of this Group Agreement;
• Upon 180 days written notice to Contract Holder (or such shorter notice as may
be permitted by Mandates, but in no event less than 30 days) if We cease to offer
a product or coverage in any market in which Members covered under this Group
Agreement reside;
• Upon 30 days written notice to Contract Holder for any other reason which is
acceptable to CMS and consistent with the Health Insurance Portability and
Accountability Act of 1996 ("HIPAA") or other Mandates; or
ME PPO GA(Y2015) 12 GRP GAPPO_2015
• Immediately upon notice to Contract Holder if Contract Holder is a member of an
employer-based association group, the Contract Holder's membership in the
association ceases.
6.4 Effect of Termination. No termination of this Group Agreement will relieve either party
from any obligation incurred before the date of termination. When terminated, this
Group Agreement and all coverage provided hereunder will end at 12:00 midnight on the
effective date of termination. We may charge the Contract Holder a reinstatement fee if
coverage is terminated and subsequently reinstated under this Group Agreement.
6.5 Notice to Members. It is the responsibility of Contract Holder to notify Members of the
termination of the Group Agreement in compliance with all Mandates and Policies and
Procedures (if any). However, We reserve the right to notify Members of termination of
the Group Agreement for any reason, including non-payment of Premium. In accordance
with the EOC and applicable CMS requirements, Contract Holder shall provide written
notice to Members of their rights upon termination of coverage under the Plan
SECTION 7. PRIVACY AND SECURITY OF INFORMATION
7.1 Compliance with Privacy and Security Laws. We and Contract Holder will abide by
all Mandates regarding confidentiality and the safeguarding of individually identifiable
health and other personal information, including the privacy and security requirements of
HIPAA.
7.2 Disclosure of Protected Health Information. We will not provide protected health
information ("PHI"), as defined in HIPAA, to Contract Holder, and Contract Holder will
not request PHI from Us, unless Contract Holder has provided the certification required
by 45 C.F.R. § 164.504(f) and amended Contract Holder's Plan documents to incorporate
the necessary changes required by such rule.
7.3 Brokers and Consultants. To the extent any broker or consultant receives PHI in the
underwriting process or while advocating on behalf of a Member, Contract Holder
understands and agrees that such broker or consultant is acting on behalf of Contract
Holder and not Us. We are entitled to rely on Contract Holder's representations that any
such broker or consultant is authorized to act on Contract Holder's behalf and entitled to
have access to the PHI under the relevant circumstances.
SECTION 8. INDEPENDENT CONTRACTOR RELATIONSHIPS
INDEMNIFICATION
8.1 Relationship Between Us and Network Providers. The relationship between Us and
providers contracted with Aetna to participate in the Plan's provider network ("Network
Providers") is a contractual relationship among independent contractors. Network
Providers are not agents or employees of Us nor are We an agent or employee of any
Network Provider.
ME PPO GA(Y2015) 13 GRP GAPPO 2015
Network Providers are solely responsible for any health services rendered to their
Members. We make no express or implied warranties or representations concerning the
qualifications, continued participation, or quality of services of any Network Provider. A
Network Provider's participation in the provider network for the Plan may be terminated
at any time without advance notice to the Contract Holder or Members, subject to
Mandates. Network Providers provide health care diagnosis, treatment and services for
Members. We administer and determine Plan benefits.
8.2 Relationship Between the Parties. The relationship between the Parties is a contractual
relationship between independent contractors. Neither Party is an agent or employee of
the other in performing its obligations pursuant to this Group Agreement.
8.3 Standard of Care. Aetna and Contract Holder will discharge their obligations under the
Group Agreement with that level of reasonable care which a similarly situated services
provider or plan sponsor, as applicable, would exercise under similar circumstances. In
connection with fiduciary powers and duties hereunder, if applicable and if delegated by
Contract Holder to Aetna, Aetna shall observe the standard of care and diligence required
of a fiduciary under ERISA Section 404(a)(1)(B).
8.4 Indemnification. Aetna shall indemnify and hold harmless Contract Holder, its directors,
officers, and employees (acting in the course of their employment, but not as Members)
for that portion of any third party loss, liability, damage, expense, settlement, cost or
obligation (including reasonable attorneys' fees) caused solely and directly by Aetna's
willful misconduct, criminal conduct, negligence, gross negligence, breach of the Group
Agreement, fraud, breach of fiduciary responsibility, failure to comply with Section 8.3
above or infringement of any U.S. patent, copyright, trademark or other intellectual
property right of a third party, related to or arising out of the services provided under the
Group Agreement.
Except as provided above, Contract Holder shall, to the extent allowed by law,
indemnify and hold harmless Aetna, its affiliates and their respective directors, officers,
and employees for that portion of any third party loss, liability, damage, expense,
settlement, cost or obligation (including reasonable attorney's fees) which was caused
solely and directly by Contract Holder's willful misconduct, criminal conduct,or its
breach of fiduciary responsibility in the case of an action under applicable Texas law,
related to or arising out of this Group Agreement.
The party seeking indemnification must notify the indemnifying party within fifteen (15)
business days in writing of any actual or threatened action, suit or proceeding to which it
claims such indemnification applies. Failure to so notify the indemnifying party shall not
be deemed a waiver of the right to seek indemnification, unless the actions of the
indemnifying party have been prejudiced by the failure of the other party to provide
notice within the required time period.
ME PPO GA(Y2015) 14 GRP GAPPO 2015
The indemnifying party may then take steps to be joined as a party to such proceeding,
and the party seeking indemnification shall not oppose any such joinder. Whether or not
such joinder takes place, the indemnifying party shall provide the defense with respect to
claims to which this section applies and in doing so shall have the right to control the
defense and settlement with respect to such claims.
The party seeking indemnification may assume responsibility for the direction of its own
defense at any time, including the right to settle or compromise any claim against it
without the consent of the indemnifying party, provided that in doing so it shall be
deemed to have waived its right to indemnification to the extent permitted by law, except
in cases where the indemnifying party has declined to defend against the claim.
Contract Holder and Aetna agree that: (i) Aetna does not render medical services or
treatments to Members; (ii) neither Contract Holder nor Aetna is responsible for the
health care that is delivered by contracting health care providers; (iii) health care
providers are solely responsible for the health care they deliver to Members; (iv) health
care providers are not the agents or employees of Contract Holder or Aetna; and (v) the
indemnification obligations above do not apply to any portion of any loss, liability,
damage, expense, settlement, cost or obligation caused by the acts or omissions of health
care providers with respect to Members.
The indemnification obligations of Aetna above shall not apply to that portion of any
loss, liability, damage, expense, settlement, cost or obligation caused by any act
undertaken by Aetna at the express written direction of Contract Holder, or by any
failure, refusal, or omission to act, directed by Contract Holder (other than services
described in the Group Agreement). The indemnification obligations under of Contract
Holder above shall not apply to that portion of any loss, liability, damage, expense,
settlement, cost or obligation caused by any act undertaken by Contract Holder at the
direction of Aetna, or by any failure, refusal, or omission to act, directed by Aetna.
The indemnification obligations under this Section 8.4 shall terminate upon the expiration
of this Group Agreement, except as to any matter concerning which a claim has been
asserted by notice to the other party on or before the statute of limitations period
applicable to such claim.
Nothing contained herein shall be construed so as to require Contract Holder to create a
sinking fund or assess, levy and collect any tax to fund its obligations under this
paragraph.
SECTION 9. MISCELLANEOUS
9.1 Delegation and Subcontracting. Contract Holder acknowledges and agrees that We
may enter into arrangements with third parties to delegate functions hereunder such as
utilization management, quality assurance and provider credentialing, as We deem
appropriate in Our sole discretion and as consistent with Mandates. Contract Holder also
acknowledges that Our arrangements with third party vendors (i.e. pharmacy, behavioral
health) are subject to change in accordance with Mandates.
ME PPO GA(Y2015) 15 GRP GAPPO 2015
9.2 Accreditation and Oualification Status. We may from time to time obtain voluntary
accreditation or qualification status from a private accreditation organization or
government agency.
9.3 Prior Agreements; Severability. As of the Effective Date, this Group Agreement
replaces and supersedes all other prior agreements between the Parties as well as any
other prior written or oral understandings, negotiations, discussions or arrangements
between the Parties related the coverage(s) addressed. If any provision of this Group
Agreement is deemed to be invalid or illegal, that provision shall be fully severable and
the remaining provisions of this Group Agreement shall continue in full force and effect.
9.4 Amendments. This Group Agreement may be amended as follows:
• This Group Agreement shall be deemed to be automatically amended to conform
with all Mandates promulgated at any time by any state or federal regulatory
agency or authority having supervisory authority over Us;
• By written agreement between both Parties; or
• By Us upon 30 days written notice to Contract Holder.
The Parties agree that an amendment does not require the consent of any Member or
other person. Except for automatic amendments to comply with Mandates, all
amendments to this Group Agreement must be approved and executed by both Parties.
No other individual has the authority to modify this Group Agreement; waive any of its
provisions, conditions, or restrictions; extend the time for making a payment; or bind Us
by making any other commitment or representation or by giving or receiving any
information.
9.5 Clerical Errors. Clerical errors or delays by Us in keeping or reporting data relative to
coverage will not reduce or invalidate a Member's coverage. Upon discovery of an error
or delay, an adjustment of Premiums shall be made. We may also modify or replace a
Group Agreement, EOC or other document issued in error.
9.6 Claim Determinations and Administration of Covered Benefits. We have complete
authority to review all claims for Covered Benefits as defined in the EOC and Schedule
of Copayments/Coinsurance under this Group Agreement. In exercising such
responsibility, We shall have discretionary authority to determine whether and to what
extent eligible individuals and beneficiaries are entitled to coverage and to construe any
disputed or doubtful terms under this Group Agreement, the EOC and Schedule of
Copayments/Coinsurance or any other document incorporated herein. We shall be
deemed to have properly exercised such authority unless We abuse Our discretion by
acting arbitrarily and capriciously. Our review of claims may include the use of
commercial software (including Claim Check) and other tools to take into account factors
such as an individual's claims history, a provider's billing patterns, complexity of the
service or treatment, amount of time and degree of skill needed and the manner of billing.
ME PPO GA(Y2015) 16 GRP GAPPO 2015
The administration of Covered Benefits and of any appeals filed by Members related to
the processing of claims for Covered Benefits shall be conducted in accordance with the
EOC and any Mandates.
9.7 Misstatements. If any fact as to the Contract Holder or a Member is found to have been
misstated, an equitable adjustment of Premiums may be made. If the misstatement
affects the existence or amount of coverage, the true facts will be used in determining
whether coverage is or remains in force and its amount.
9.8 Incontestability. Except as to a fraudulent misstatement, or issues concerning Premiums
due:
• No statement made by Contract Holder or any Member shall be the basis for
voiding coverage or denying coverage or be used in defense of a claim unless it is
in writing.
• No statement made by Contract Holder shall be the basis for voiding this Group
Agreement after it has been in force for two years from its effective date.
9.9 Assignability. No rights or benefits under this Group Agreement are assignable by
Contract Holder to any other Party unless approved by Aetna.
9.10 Waiver. Failure to implement, or insist upon compliance with, any provision of this
Group Agreement or the terms of the EOC incorporated hereunder, at any given time or
times, shall not constitute a waiver of Our right to implement or insist upon compliance
with that provision at any other time or times. This includes, but is not limited to, the
payment of Premiums or benefits. This applies whether or not the circumstances are the
same.
9.11 Notices. Any notice required or permitted under this Group Agreement shall be in
writing and shall be deemed to have been given on the date when delivered in person; or,
if delivered by first-class United States mail, on the date mailed, proper postage prepaid,
and properly addressed to the address set forth in the Group Application or Cover Sheet,
or to any more recent address of which the sending Party has received written notice or, if
delivered by facsimile or other electronic means, on the date sent by facsimile or other
electronic means.
9.12 Third Parties. This Group Agreement shall not confer any rights or obligations on third
parties except as specifically provided herein.
9.13 Non-Discrimination. Contract Holder agrees to make no attempt, whether through
differential contributions or otherwise, to encourage or discourage enrollment in the
Aetna Medicare PPO plan of eligible individuals and eligible dependents based on health
status or health risk.
ME PPO GA(Y2015) 17 GRP GAPPO 2015
9.14 Compliance with Law. Aetna and Contract Holder shall comply with all Mandates
applicable to the performance of their respective obligations under this Group
Agreement.
9.15 Applicable Law. This Group Agreement shall be governed and construed in accordance
with applicable federal law and the applicable law, if any, of the state specified in the
Cover Sheet or, if no state law is specified, Our domicile state.
9.16 Inability to Arrange Services. If due to circumstances not within Our reasonable
control, including but not limited to major disaster, epidemic, complete or partial
destruction of facilities, riot, civil insurrection, disability of a significant part of Our
Network Providers or entities with whom We have contracted for services under this
Group Agreement, or similar materials which describe the Plan, the provision of
medical or hospital benefits or other services provided under this Group Agreement is
delayed or rendered impractical, We shall not have any liability or obligation on account
of such delay or failure to provide services, except to refund the amount of the unearned
prepaid Premiums held by Us on the date such event occurs. We are required only to
make a good-faith effort to provide or arrange for the provision of services, taking into
account the impact of the event.
9.17 Use of the Aetna Name and all Symbols, Trademarks, and Service Marks. We
reserve the right to control the use of Our name and all symbols, trademarks, and service
marks presently existing or subsequently established. Contract Holder agrees that it will
not use such name, symbols, trademarks, or service marks in advertising or promotional
materials or otherwise without Our prior written consent and will cease any and all usage
immediately upon Our request or upon termination of this Group Agreement.
9.18 Workers' Compensation. In accordance with 42 C.F.R. Section 422.108, as may be
amended from time to time, and other Mandates, Contract Holder is responsible for
protecting Our interests in any Workers' Compensation claims or settlements with any
Member. We shall be reimbursed for all paid medical expenses which have occurred as a
result of any work related injury that is compensable or settled in any manner.
Upon Our request, Contract Holder shall also submit a monthly report to Us listing all
Workers' Compensation cases for Members who have outstanding Workers'
Compensation claims involving the Contract Holder. Such list will contain the name,
social security number, date of loss and diagnosis of all applicable Members.
9.19 Medicare Secondary Payer Requirements.
• Generally. Aetna and Contract Holder agree to comply with all Medicare
Secondary Payer ("MSP") Mandates that apply to Contract Holder, the Plan and
Aetna("MSP Requirements").
ME PPO GA(Y2015) 18 GRP GAPPO 2015
• MSP Requirements Applicable to Medicare Beneficiaries Diagnosed with End
Stage Renal Disease ("ESRD"). Aetna and Contract Holder agree to comply with
all MSP Requirements applicable to Contract Holder's active employees and
retirees and their dependents who are Medicare beneficiaries diagnosed with
ESRD ("ESRD Beneficiaries" or "ESRD Beneficiary"), including, without
limitation, those MSP Requirements set forth in 42 U.S.C. § 1395y(b)(1)(C), 42
C.F.R. §§ 411.102(a), 411.161, and 411.162 and 42 C.F.R. §§ 422.106 and
422.108 ("ESRD MSP Requirements").
• Contract Holder acknowledges and agrees that if an ESRD Beneficiary is eligible
for or entitled to Medicare based on ESRD, the MSP Requirements require the
commercial group health plan offered by Contract Holder ("GHP") to be the
primary payer for the first thirty(30) months of the ESRD Beneficiary's Medicare
eligibility or entitlement ("30-month coordination period"), regardless of the
number of employees employed by Contract Holder and regardless of whether the
ESRD Beneficiary is a current employee or retiree.
• In furtherance of Aetna's and Contract Holder's compliance with ESRD MSP
Requirements, Contract Holder agrees to confirm to Aetna whether ESRD
Beneficiaries are in their 30-month coordination period, and not seek to enroll
ESRD Beneficiaries in the Plan during their 30-month coordination period unless
coverage under the GHP is maintained for such ESRD Beneficiaries for that
period. If Contract Holder seeks to enroll an ESRD Beneficiary in the Plan,
Contract Holder agrees to provide Aetna, upon request, with information or
documentation to verify compliance with ESRD MSP Requirements, including
any MSP reporting or other requirements established by CMS.
9.20 Service Area Extension &Network Adequacy for Plan. To enable employers/unions
to offer group Medicare Advantage ("MA") plans to all of their Medicare-eligible
retirees/dependents wherever they reside, CMS has established a waiver of service area
requirements ("Waiver")for organizations that are approved by CMS to offer MA plans
("MAOs"). Under this Waiver, MAOs offering a group MA plan in a given service area,
as defined by CMS ("Service Area"), can extend coverage to an employer/union
sponsor's Medicare-eligible retirees/dependents residing outside of that Service Area,
even if the MAO does not offer a provider network for the group MA plan ("Provider
Network") that meets CMS network adequacy requirements in that Service Area
("Extended Service Area").
Aetna and Contract Holder agree that Aetna will use this Waiver to offer the Plan to
Members who reside in an Extended Service Area. The Parties acknowledge that Aetna
must meet certain CMS requirements to offer the Plan in an Extended Service Area, and
these requirements include, but are not limited to, the following:
(1) at least 51% of retirees/dependents who are currently enrolled in Aetna MA HMO
or PPO plans offered by Contract Holder must be enrolled in an Aetna MA HMO
or PPO plan that offers a Provider Network that meets CMS network adequacy
requirements, and
ME PPO GA(Y2015) 19 GRP GAPPO 2015
(2) all Members must receive the same Covered Benefits at the preferred in-network
cost-sharing for all Covered Benefits.
The Parties agree to comply with all Mandates that apply to use of this Waiver. Further,
Contract Holder acknowledges and agrees that: (1) Members who reside in an Extended
Service Area do not have access to a Provider Network that meets CMS network
adequacy requirements, and (2) health care providers and suppliers that are not contracted
with Aetna to participate in the Provider Network are not required to accept the Plan and
furnish Covered Benefits to Members who reside inside or outside of an Extended
Service Area, except as required under Mandates. Failure to meet CMS requirements of
this Waiver may result in termination of the Plan in Extended Service Areas.
9.21 Order of Priority. In the event of any conflict between the terms and conditions of
the Financial Conditions and those of the Group Agreement between Contract
Holder and Aetna,the terms and conditions of the Group Agreement will control.
9.22 Disease Management/Care Management Programs. From time to time, Aetna may
offer and administer programs for Members that are designed to improve quality of care,
ensure access to Covered Benefits and/or coordinate care delivered to Members under the
Plan ("Disease/Care Management Programs"). Aetna will administer Disease/Care
Management Programs consistent with Mandates and monitor the performance of
Disease/Care Management Programs on an ongoing basis. Contract Holder
acknowledges that Aetna may determine, in its sole discretion and judgment, to
discontinue offering a Disease/Care Management Program to Members at any time,
consistent with Mandates.
ME PPO GA(Y2015) 20 GRP GAPPO 2015
City of Fort Worth
MEDICARE ADVANTAGE RATE PROPOSAL
Plan Sponsor Number: 889000
Policy Period Start Date: 01/01/2015
Policy Period End Date: 12/31/2015
Medical Plan: Medicare (C04) ESA PPO
Hearing Hardware: $2,000/36 months
Lens Reimbursement: Vision 200
Pharmacy Plan: FI new Disc_3SC
e Please refer to the Financial Conditions and Plan Design Exhibits for an outline of the level
of benefits quoted, as well as the
terms and conditions of this proposal.
e All rates are on a Per Member Per Month (PMPM) basis.
e Filed benefits (including copayment amounts), value added services and premiums are
subject to CMS approval, and are effective January 1, 2015 through December 31, 2015.
e All counties are included where Aetna Medicare is available.
e The Patient Protection and Affordable Care Act imposes a new Health Insurer Fee
(hereinafter"Fee"). The Fee is effective as of January 1, 2014. This rate quote includes,where
permitted,the estimated proportionate allocation of this Fee:
Medical Health Insurer Fee: $33.07
Rx Health Insurer Fee: $5.48
Total Health Insurer Fee: $38.54
ME PPO GA(Y2015) 21 GRP GAPPO 2015
a The national average medical and pharmacy rates are shown in the table below, for reference
purposes. These plans are not being offered on a national basis. The detailed rate table below
displays the actual rates that apply.
Medical Rx Total
Current $179.84 N/A $179.84
Proposed $189.55 $133.90 $323.45
Change $9.71 $139.90 $149.61!
% Change 5.4% N/A
Total Medicare Eligible Members 1,824
Medicare Eligible Medical Pharmacy
State Total Rate
Members Rate Rate
Alaska 1 $189.55 $133.90 $323.45
Arizona 2 $189.55 $133.90 $323.45
Arkansas 5 $189.55 $133.90 $323.45
California 0 $189.55 $133.90 $323.45
Florida 8 $189.55 $133.90 $323.45
Georgia 5 $189.55 $133.90 $323.45
Illinois 1 $189.55 $133.90 $323.45
Indiana 2 $189.55 $133.90 $323.45
Kansas 1 $189.55 $133.90 $323.45
Louisiana 1 $189.55 $133.90 $323.45
Massachusetts 2 $189.55 $133.90 $323.45
Michigan 1 $189.55 $133.90 $323.45
Minnesota 1 $189.55 $133.90 $323.45
Mississippi 3 $189.55 $133.90 $323.45
Missouri 7 $189.55 $133.90 $323.45
New Hampshire 2 $189.55 $133.90 $323.45
New Mexico 4 $189.55 $133.90 $323.45
North Carolina 3 $189.55 $133.90 $323.45
Ohio 1 $189.55 $133.90 $323.45
Oklahoma 9 $189.55 $133.90 $323.45
Oregon 1 $189.55 $133.90 $323.45
Pennsylvania 1 $189.55 $133.90 $323.45
ME PPO GA(Y2015) 22 GRP GAPPO 2015
South Carolina 0 $189.55 $133.90 $323.45
Tennessee 0 $189.55 $133.90 $323.45
Texas 1759 $189.55 $133.90 $323.45
Virginia 1 $189.55 $133.90 $323.45
Washington 2 $189.55 $133.90 $323.45
Wyoming 1 $189.55 $133.90 $323.45
ME PPO GA(Y2015) 23 GRP GAPPO 2015
Exhibit A
aetna
January 1, 2015 —December 31, 2015
Evidence of Coverage:
Your Medicare Health Benefits and Services and Prescription Drug Coverage
as a Member of Aetna Medicaresm Plan (PPO).
This booklet gives you the details about your Medicare health care and prescription drug
coverage from January 1, 2015 — December 31, 2015. It explains how to get coverage for the
health care services and prescription drugs you need. This is an important legal document.
Please keep it in a safe place.
This plan,Aetna Medicare Plan (PPO), is offered by Aetna Life Insurance Company. (When this
Evidence of Coverage says "we," "us," or"our," it means Aetna Life Insurance Company. When
it says "plan" or"our plan," it means Aetna Medicare Plan (PPO).)
Aetna Medicare is a PPO plan with a Medicare contract. Enrollment in Aetna Medicare depends
on contract renewal.
This information is available for free in other languages. Please contact Customer Service at the
telephone number printed on the back of your member ID card for additional information. You
may also call our general customer service center at 1-855-660-1810. (For TTY assistance,
please dial 711.) We're available 8 a.m. to 6 p.m. local time, Monday through Friday. Customer
Service also has free language interpreter services available for non-English speakers.
Esta informaci6n esta disponible en otros idiomas de manera gratuita. Si desea mas informaci6n,
comunfquese con Servicios al Cliente al n6mero en el dorso de su tarjeta de identificacion de
miembro. Tambien puede llamar a nuestro centro de servicio al cliente en general, al 1-855-660-
1810. (Los usuarios de TTY deben llamar al 711.) Estamos disponibles de 8 a.m. a 6 p.m. hora
local, el lunes por al viernes. Las personas que no hablan ingles pueden solicitar el servicio
gratuito de interpretes a Servicios al Cliente.
This document may be made available in other formats such as Braille, large print or other
alternate formats. Please contact Customer Service for more information.
Benefits, formulary, pharmacy network, premium, deductible, and/or copayments/coinsurance
may change on January 1 st.
EGWP CCP D2 2015 ESA PPO EOC-with Rx(Y2015)
2015 Evidence of Coverage for Aetna MedicaresM Plan (PPO)
Table of Contents
2015 Evidence of Coverage
Table of Contents
This list of chapters and page numbers is your starting point. For more help in finding
information you need, go to the first page of a chapter. You will find a detailed list of topics at
the beginning of each chapter.
Chapter 1. Getting started as a member................................................................4
Explains what it means to be in a Medicare health plan and how to use
this booklet. Tells about materials we will send you, your plan premium,
your plan membership card, and keeping your membership record up to
date.
Chapter 2. Important phone numbers and resources............................................ 16
Tells you how to get in touch with our plan (Aetna Medicare Plan
(PPO)) and with other organizations including Medicare,the State
Health Insurance Assistance Program (SHIP), the Quality Improvement
Organization, Social Security,Medicaid(the state health insurance
program for people with low incomes),programs that help people pay
for their prescription drugs, and the Railroad Retirement Board.
Chapter 3. Using the plan's coverage for your medical services........................... 31
Explains important things you need to know about getting your medical
care as a member of our plan. Topics include using the providers in the
plan's network and how to get care when you have an emergency.
Chapter 4. Medical Benefits Chart(what is covered and what you pay).............. 43
Gives the details about which types of medical care are covered and not
covered for you as a member of our plan. Explains how much you will
pay as your share of the cost for your covered medical care.
Chapter 5. Using the plan's coverage for your Part D prescription drugs ........... 50
Explains rules you need to follow when you get your Part D drugs. Tells
how to use the plan's List of Covered Drugs (Formulary) to find out
which drugs are covered. Tells which kinds of drugs are not covered.
Explains several kinds of restrictions that apply to coverage for certain
drugs. Explains where to get your prescriptions filled. Tells about the
plan's programs for drug safety and managing medications.
Chapter 6. What you pay for your Part D prescription drugs.............................. 70
Tells about the four stages of drug coverage (Deductible Stage, Initial
Coverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage)
and how these stages affect what you pay for your drugs. Explains the
different cost-sharing tiers for your Part D drugs and tells what you must
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Table of Contents
pay for a drug in each cost-sharing tier. Tells about the late enrollment
penalty.
Chapter 7. Asking us to pay our share of a bill you have received for covered
medical services or drugs...................................................................... 89
Explains when and how to send a bill to us when you want to ask us to
pay you back for our share of the cost for your covered services or
drugs.
Chapter 8. Your rights and responsibilities........................................................... 96
Explains the rights and responsibilities you have as a member of our
plan. Tells what you can do if you think your rights are not being
respected.
Chapter 9. What to do if you have a problem or complaint (coverage
decisions, appeals, complaints)............................................................. 113
Tells you step-by-step what to do if you are having problems or
concerns as a member of our plan.
• Explains how to ask for coverage decisions and make appeals if
you are having trouble getting the medical care or prescription
drugs you think are covered by our plan. This includes asking us
to make exceptions to the rules or extra restrictions on your
coverage for prescription drugs, and asking us to keep covering
hospital care and certain types of medical sei vices if you think
your coverage is ending too soon.
• Explains how to make complaints about quality of care,waiting
times, customer service, and other concerns.
Chapter 10. Ending your membership in the plan................................................... 160
Explains when and how you can end your membership in the plan.
Explains situations in which our plan is required to end your
membership.
Chapter11. Legal notices.......................................................................................... 169
Includes notices about governing law and about nondiscrimination.
Chapter12. Definitions of important words ............................................................ 173
Explains key terms used in this booklet.
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Chapter 1. Getting started as a member
SECTION1 Introduction...................................................................................................... 5
Section 1.1 You are enrolled in Aetna Medicare Plan (PPO), which is a
MedicarePPO............................................................................. 5
Section 1.2 What is the Evidence of Coverage booklet about?........................ 5
Section 1.3 What does this chapter tell you?.................................................. 5
Section 1.4 What if you are new to our plan?................................................. 5
Section 1.5 Legal information about the Evidence of Coverage...................... 6
SECTION 2 What makes you eligible to be a plan member?.............................................. 6
Section 2.1 Your eligibility requirements....................................................... 6
Section 2.2 What are Medicare Part A and Medicare Part B?......................... 6
Section 2.3 The plan service area................................................................... 7
SECTION 3 What other materials will you get from us?.................................................... 7
Section 3.1 Your plan membership card—Use it to get all covered care and
prescription drugs........................................................................ 7
Section 3.2 The Provider Directory: Your guide to all providers in the
plan's network............................................................................. 8
Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our
network....................................................................................... 9
Section 3.4 The plan's List of Covered Drugs (Formulary)............................ 9
Section 3.5 The Part D Explanation of Benefits(the "Part D EOB"):
Reports with a summary of payments made for your Part D
prescription drugs........................................................................ 9
SECTION 4 Your monthly premium for our plan (if applicable)....................................... 10
Section 4.1 How much is your plan premium (if applicable)? ........................ 10
Section 4.2 There are several ways you can pay your plan premium (if
applicable)................................................................................... 11
Section 4.3 Can we change your monthly plan premium (if applicable)
duringthe year?........................................................................... 13
SECTION 5 Please keep your plan membership record up to date.................................... 13
Section 5.1 How to help make sure that we have accurate information
aboutyou .................................................................................... 13
SECTION 6 We protect the privacy of your personal health information ......................... 14
Section 6.1 We make sure that your health information is protected............... 14
SECTION 7 How other insurance works with our plan...................................................... 14
Section 7.1 Which plan pays first when you have other insurance?................ 14
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SECTION 1 Introduction
Section 1.1 You are enrolled in Aetna Medicare Plan (PPO),which is a Medicare
PPO
Your coverage is provided through a contract with your current employer or former employer/
union/trust. You are covered by Medicare, and you get your Medicare health care and
prescription drug coverage through our plan,Aetna Medicare Plan (PPO).
There are different types of Medicare health plans. Our plan is a Medicare Advantage PPO Plan
(PPO stands for Preferred Provider Organization). Like all Medicare health plans,this Medicare
PPO is approved by Medicare and run by a private company.
Section 1.2 What is the Evidence of Coverage booklet about?
This Evidence of Coverage booklet tells you how to get your Medicare medical care and
prescription drugs covered through our plan. This booklet explains your rights and
responsibilities, what is covered, and what you pay as a member of the plan.
This plan,Aetna Medicare Plan (PPO), is offered by Aetna Life Insurance Company. (When this
Evidence of Coverage says "we," "us," or"our," it means Aetna Life Insurance Company. When
it says"plan" or"our plan," it means Aetna Medicare Plan (PPO).)
The word "coverage" and "covered services" refers to the medical care and services and the
prescription drugs available to you as a member of our plan.
Section 1.3 What does this chapter tell you?
Look through Chapter 1 of this Evidence of Coverage to learn:
What makes you eligible to be a plan member?
• What is your plan's service area?
• What materials will you get from us?
• How to pay your plan premium(if applicable)
• How do you keep the information in your membership record up to date?
Section 1.4� What if you are new to our plan?
If you are a new member, then it's important for you to learn what the plan's rules are and what
services are available to you. We encourage you to set aside some time to look through this
Evidence of Coverage booklet.
If you are confused or concerned or just have a question, please contact our plan's Customer
Set-vice (phone numbers are printed on the back of your member ID card).
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Section 1.5Legal information about theEvidence ofCoverage
It's part of our contract with you
This Evidence of Coverage is part of our contract with you about how our plan covers your care.
Other parts of this contract include your enrollment form, the List of Covered Drugs
(Formulary), and any notices you receive from us about changes to your coverage or conditions
that affect your coverage. These notices are sometimes called"riders" or"amendments."
The contract is in effect for months in which you are enrolled in our plan between January 1, 2015
—December 31, 2015.
Each calendar year, Medicare allows us to make changes to the plans that we offer. This means
we can change the costs and benefits of our plan after December 31, 2015. We can also choose to
stop offering the plan, or to offer it in a different service area, after December 31,2015.
Medicare must approve our plan each year
Medicare (the Centers for Medicare & Medicaid Services) must approve our plan each year.
Your former employer/union/trust can continue to offer you Medicare coverage as a member of
our plan as long as we choose to continue to offer the plan and Medicare renews its approval of
the plan.
SECTION 2 What makes you eligible to be a plan member?
Section 2.1 Your eligibility requirements
You are eligible for membership in our plan as long as:
• You live in our geographic service area(section 2.3 below describes our service area)
• and—you have both Medicare Part A and Medicare Part B
• and— if you have Medicare because you have End-Stage Renal Disease (ESRD),you are
not within the first 30 months of becoming eligible for or entitled to Medicare (referred to
as your"30 month coordination period").
Section 2.2 What are Medicare Part A and Medicare Part B?
When you first signed up for Medicare, you received information about what services are
covered under Medicare Part A and Medicare Part B. Remember:
• Medicare Part A generally helps cover services provided by hospitals for inpatient
services, skilled nursing facilities, or home health agencies.
• Medicare Part B is for most other medical services (such as physician's services and
other outpatient services) and certain items (such as durable medical equipment and
supplies).
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Section 2.3 The plan service area
Although Medicare is a federal program, our plan is available only to individuals who live in our
plan service area. To remain a member of our plan, you must continue to reside in the plan
service area. Addendum B at the back of this Evidence of Coverage lists the Aetna Medicare
(PPO) set-vice areas. Your former employer/union/trust offers you coverage through our plan's
extended service area feature.
If you move outside of your service area, you will have a Special Enrollment Period that will
allow you to switch to a different plan. Please contact your former employer/union/trust plan
administrator to see what other plan options are available to you in your new location.
If you move,please contact Customer Service at the telephone number on your member ID card.
It is also important that you call Social Security if you move or change your mailing address.
You can find phone numbers and contact information for Social Security in Chapter 2, Section 5.
SECTION 3 What other materials will you get from us?
Section 3.1 Your plan membership card—Use it to get all covered care and
prescription drugs
While you are a member of our plan, you must use your membership card for our plan whenever
you get any services covered by this plan and for prescription drugs you get at network
pharmacies. Here's a sample membership card to show you what yours will look like:
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As long as you are a member of our plan you must not use your red, white, and blue
Medicare card to get covered medical services (with the exception of routine clinical research
studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in
case you need it later.
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Here's why this is so important: If you get covered services using your red, white, and blue
Medicare card instead of using your Aetna Medicare membership card while you are a plan
member, you may have to pay the full cost yourself.
If your plan membership card is damaged, lost, or stolen, call Customer Service right away and
we will send you a new card. (Phone numbers for Customer Service are printed on the back of
this booklet.)
Section 3.2 The Provider Directory: Your guide to all providers in the plan's
network
The Provider Directory lists our network providers.
You are a member of our plan through our extended service area feature. Aetna Medicare may
or may not have a provider network where you live. Our network is a group of doctors,
hospitals, and other health care experts contracted by Aetna to provide covered services to its
members. Network providers are independent contractors and not agents of Aetna.
What are "network providers"?
Network providers are the doctors and other health care professionals, medical groups,
hospitals, and other health care facilities that have an agreement with us to accept our payment
and any plan cost-sharing as payment in full. We have arranged for these providers to deliver
covered services to members in our plan.
Why do you need to know which providers are part of our network?
As a member of our plan, you may use network providers and out-of-network providers for all
covered medical services at the same member cost sharing amount. Our plan will cover services
from either in-network or out-of-network providers, as long as the services are covered benefits
and medically necessary. See Chapter 3 (Using the plan's coverage for your medical services)
for more specific information.
If you don't have your copy of the Provider Directory and you reside in a network service area,
you can request a copy from Customer Service (phone numbers are printed on the back of this
booklet). A listing of network service areas is available in Addendum B at the back of this
Evidence of Coverage. You may ask Customer Service for more information about our network
providers, including their qualifications. You can also see the Provider Directory at
http://www.actnaretireeplans.com, or download it from this website. Both Customer Service and
the website can give you the most up-to-date information about changes in our network
providers.
Out-of-network providers must be eligible to receive payment under Medicare and willing to
accept our plan. To find a provider that participates with Original Medicare, go to
http://www.medicare.gov.
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Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our network
What are "network pharmacies"?
Our Pharmacy Directory gives you a complete list of our network pharmacies—that means all of
the pharmacies that have agreed to fill covered prescriptions for our plan members.
Why do you need to know about network pharmacies?
You can use the Pharmacy Directory to find the network pharmacy you want to use. This is
important because, with few exceptions, you must get your prescriptions filled at one of our
network pharmacies if you want our plan to cover(help you pay for)them.
The Pharmacy Directory will also tell you which of the pharmacies in our network have
preferred cost-sharing (if included in your plan), which may be lower than the standard cost-
sharing offered by other network pharmacies.
If you don't have the Pharmacy Directory, you can get a copy from Customer Service (phone
numbers are printed on the back of your member ID card). At any time, you can call Customer
Service to get up-to-date information about changes in the pharmacy network. You can also find
this information on our website at http://www.aetnaretireeplans.com.
Section 3.4 The plan's List of Covered Drugs (Formulary)
The plan has a List of Covered Drugs (Formulary). We call it the "Drug List" for short. It tells
which Part D prescription drugs are covered by our plan. The drugs on this list are selected by
the plan with the help of a team of doctors and pharmacists. The list must meet requirements set
by Medicare. Medicare has approved the Aetna Medicare Drug List.
The Drug List also tells you if there are any rules that restrict coverage for your drugs.
We will send you a copy of the Drug List. To get the most complete and current information
about which drugs are covered, you can visit the plan's website
(http://www.aetnaretireeplans.com) or call Customer Service (phone numbers are printed on the
back of your member ID card).
Section 3.5 The Part D Explanation of Benefits (the"Part D EOB"): Reports with
a summary of payments made for your Part D prescription drugs
When you use your Part D prescription drug benefits,we will send you a summary report to help
you understand and keep track of payments for your Part D prescription drugs. This summary
report is called the Part D Explanation of Benefits(or the "Part D EOB").
The Part D Explanation of Benefits tells you the total amount you, or others on your behalf,have
spent on your Part D prescription drugs and the total amount we have paid for each of your Part
D prescription drugs during the month. Chapter 6 (What you pay for your Part D prescription
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drugs) gives more information about the Part D Explanation of Benefits and how it can help you
keep track of your drug coverage.
A Part D Explanation of Benefits summary is also available upon request. To get a copy,please
contact Customer Service (phone numbers are printed on the back of your member ID card).
SECTION 4 Your monthly premium for our plan (if applicable)
Section 4.1 How much is your plan premium (if applicable)?
Your coverage is provided through a contract with your current employer or former
employer/union/trust. Your plan benefits administrator will let you know about your plan
premium, if any.
If you have an Aetna plan premium and are billed directly by Aetna Medicare for the full amount
of the premium, we will notify you of your plan premium amount before the start of the plan
year. If you have an Aetna plan premium and you are not billed directly by Aetna Medicare for
this premium, please refer to your plan benefits administrator for any premium payment
information.
In addition, you must continue to pay your Medicare Part B premium (unless your Part B
premium is paid for you by Medicaid or another third parry).
In some situations,your plan premium could be less
There are programs to help people with limited resources pay for their drugs. These include
"Extra Help" and State Pharmaceutical Assistance Programs. Chapter 2, Section 7 tells more
about these programs. If you qualify, enrolling in the program might lower your monthly plan
premium.
If you are already enrolled and getting help from one of these programs, the information about
premiums in this Evidence of Coverage may not apply to you. We send you a separate insert,
called the "Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription
Drugs" (also known as the "Low Income Subsidy Rider" or the "LIS Rider"), which tells you
about your drug coverage. If you don't have this insert, please call Customer Service and ask for
the "LIS Rider." (Phone numbers for Customer Service are printed on the back of your member
ID card.)
In some situations,your plan premium could be more
Some members are required to pay a late enrollment penalty because they did not join a
Medicare drug plan when they first became eligible or because they had a continuous period of
63 days or more when they didn't have "creditable" prescription drug coverage. ("Creditable"
means the drug coverage is at least as good as Medicare's standard drug coverage.) For these
members, the late enrollment penalty is added to the plan's monthly premium. Their premium
amount will be the monthly plan premium plus the amount of their late enrollment penalty.
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• If you are required to pay the late enrollment penalty, the amount of your penalty depends
on how long you waited before you enrolled in drug coverage or how many months you
were without drug coverage after you became eligible. Chapter 6, Section 9 explains the
late enrollment penalty.
• If you have a late enrollment penalty and do not pay it, you could be disenrolled from the
plan.
Many members are required to pay other Medicare premiums
In addition to paying the monthly plan premium (if applicable), many members are required to
pay other Medicare premiums. As explained in Section 2 above, in order to be eligible for our
plan, you must be entitled to Medicare Part A and enrolled in Medicare Part B. For that reason,
some plan members (those who aren't eligible for premium-free Part A) pay a premium for
Medicare Part A. And most plan members pay a premium for Medicare Part B. You must
continue paying your Medicare premiums to remain a member of the plan.
Some people pay an extra amount for Part D because of their yearly income. This is known as
Income Related Monthly Adjustment Amounts, also known as IRMAA. If your income is
$85,000 or above for an individual (or married individuals filing separately) or $170,000 or
above for married couples, you must pay an extra amount directly to the government (not the
Medicare plan) for your Medicare Part D coverage.
• If you are required to pay the extra amount and you do not pay it, you will be
disenrolled from the plan and lose prescription drug coverage.
• If you have to pay an extra amount, Social Security, not your Medicare plan, will
send you a letter telling you what that extra amount will be.
• For more information about Part D premiums based on income, go to Chapter 6,
Section 10 of this booklet. You can also visit http://www.medicare.gov on the Web or
call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048. Or you may call Social Security at 1-800-772-1213. TTY
users should call 1-800-325-0778.
Your copy of Medicare & You 2015 gives information about the Medicare premiums in the
section called "2015 Medicare Costs." This explains how the Medicare Part B and Part D
premiums differ for people with different incomes. Everyone with Medicare receives a copy of
Medicare & You each year in the fall. Those new to Medicare receive it within a month after first
signing up. You can also download a copy of Medicare & You 2015 from the Medicare website
(http://www.medicare.gov). Or, you can order a printed copy by phone at 1-800-MEDICARE(1-
800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.
Section 4.2 There are several ways you can pay your plan premium (if applicable)
Your coverage is provided through a contract with your current employer or former
employer/union/trust. For most members, your plan benefits administrator will provide you with
information about your plan premium (if applicable).
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If Aetna bills you directly for your total plan premium, we will snail you a letter detailing your
premium amount. (You must also continue to pay your Medicare Part B premium.) For
members who have an Aetna plan premium and are billed directly by Aetna, there are several
ways you can pay your plan premium, including by check, electronic payment or automatic
withdrawal. You may inform us of your premium payment option choice or change your choice
by calling Customer Service at the numbers printed on the back of your member ID card. If you
decide to change the way you pay your premium, it can take up to three months for your new
payment method to take effect. While we are processing your request for a new payment method,
you are responsible for making sure that your plan premium is paid on time.
What to do if you are having trouble paying your plan premium
If you are billed directly by Aetna, your plan premium is due in our office by the first day of the
month. If we have not received your premium by the first day of the month, we will send you a
notice telling you that your plan membership will end if we do not receive your premium within
a three-month period. If you are required to pay a late enrollment penalty, you must pay the
penalty to keep your prescription drug coverage. We will mail a reminder notice to you.
If you are having trouble paying your premium on time, please contact Customer Service to see
if we can direct you to programs that will help with your plan premium. (Phone numbers for
Customer Service are printed on the back of this booklet.)
If we end your membership with the plan because you did not pay your plan premium, then you
may not be able to receive Part D coverage until the following year if you enroll in a new plan
during the annual enrollment period. During the annual enrollment period, you may either join a
stand-alone prescription drug plan or a health plan that also provides drug coverage. (If you go
without"creditable" drug coverage for more than 63 days, you may have to pay a late enrollment
penalty for as long as you have Part D coverage.)
If we end your membership because you did not pay your premium, you will have health
coverage under Original Medicare.
At the time we end your membership, you may still owe us for premiums you have not paid. In
the future, if you want to enroll again in our plan (or another plan that we offer),you may need to
pay the amount you owe before you can enroll.
If you think we have wrongfully ended your membership, you have a right to ask us to
reconsider this decision by making a complaint. Chapter 9, Section 10 of this booklet tells how to
make a complaint. If you had an emergency circumstance that was out of your control and it
caused you to not be able to pay your premiums within our grace period, you can ask Medicare
to reconsider this decision by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7
days a week. TTY users should call 1-877-486-2048.
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Section 4.3 Can we change your monthly plan premium (if applicable) during the
year?
No. We are not allowed to change the amount we charge for the plan's monthly plan premium
during the year. If the monthly plan premium changes for next year the change will take effect on
January 1.
However, in some cases the part of the premium that you have to pay can change during the year.
This happens if you become eligible for the "Extra Help" program or if you lose your eligibility
for the "Extra Help" program during the year. If a member qualifies for "Extra Help" with their
prescription drug costs, the "Extra Help" program will pay part of the member's monthly plan
premium. So a member who becomes eligible for "Extra Help" during the year would begin to
pay less towards their monthly premium. And a member who loses their eligibility during the
year will need to start paying their full monthly premium. You can find out more about the
"Extra Help"program in Chapter 2, Section 7.
SECTION 5 Please keep your plan membership record up to date
Section 5.1 How to help make sure that we have accurate information about you
Your membership record has information from your enrollment form, including your address and
telephone number. It shows your specific plan coverage including your Primary Care
Provider/Medical Group/IPA. (An IPA, or Independent Practice Association, is an independent
group of physicians and other health-care providers under contract to provide services to
members of managed care organizations.)
The doctors, hospitals, pharmacists, and other providers in the plan's network need to have
correct information about you. These network providers use your membership record to
know what services and drugs are covered and the cost-sharing amounts for you. Because
of this, it is very important that you help us keep your information up to date.
Let us know about these changes:
• Changes to your name, your address, or your phone number
® Changes in any other health insurance coverage you have (such as from your employer,
your spouse's employer,workers' compensation, or Medicaid)
• If you have any liability claims, such as claims from an automobile accident
• If you have been admitted to a nursing home
• If you receive care in an out-of-area or out-of-network hospital or emergency room
• If your designated responsible party(such as a caregiver) changes
• If you are participating in a clinical research study
If any of this information changes, please let us know by calling Customer Service (phone
numbers are printed on the back of your member ID card).
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Chapter 1. Getting started as a member 14
It is also important to contact Social Security if you move or change your mailing address. You
can find phone numbers and contact information for Social Security in Chapter 2, Section 5.
Read over the information we send you about any other insurance coverage you have
Medicare requires that we collect information from you about any other medical or drug
insurance coverage that you have. That's because we must coordinate any other coverage you
have with your benefits under our plan. (For more information about how our coverage works
when you have other insurance, see Section 7 in this chapter.)
Once each year, we will send you a letter that lists any other medical or drug insurance coverage
that we know about. Please read over this information carefully. If it is correct, you don't need to
do anything. If the information is incorrect, or if you have other coverage that is not listed,please
call Customer Service (phone numbers are printed on the back of your member ID card).
SECTION 6 We protect the privacy of your personal health information
Section 6.1 We make sure that your health information is protected
Federal and state laws protect the privacy of your medical records and personal health
information. We protect your personal health information as required by these laws.
For more information about how we protect your personal health information, please go to
Chapter 8, Section 1.4 of this booklet.
SECTION 7 How other insurance works with our plan
Section 7.1 Which plan pays first when you have other insurance?
When you have other insurance (like coverage under another employer group health plan), there
are rules set by Medicare that decide whether our plan or your other insurance pays first. The
insurance that pays first is called the "primary payer" and pays up to the limits of its coverage.
The one that pays second, called the "secondary payer," only pays if there are costs left
uncovered by the primary coverage. The secondary payer may not pay all of the uncovered costs.
These rules apply for employer or union group health plan coverage:
• If you have retiree coverage, Medicare pays first.
• If your group health plan coverage is based on your or a family member's current
employment, who pays first depends on your age, the number of people employed by
your employer, and whether you have Medicare based on age, disability, or End-stage
Renal Disease (ESRD):
o If you're under 65 and disabled and you or your family member is still working,
your plan pays first if the employer has 100 or more employees or at least one
employer in a multiple employer plan that has more than 100 employees.
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Chapter 1. Getting started as a member 15
o If you're over 65 and you or your spouse is still working,the plan pays first if the
employer has 20 or more employees or at least one employer in a multiple
employer plan that has more than 20 employees.
• If you have Medicare because of ESRD, your group health plan will pay first for the first
30 months after you become eligible for Medicare even if you are retired.
These types of coverage usually pay first for services related to each type:
• No-fault insurance (including automobile insurance)
• Liability(including automobile insurance)
• Black lung benefits
• Workers' compensation
Medicaid and TRICARE never pay first for Medicare-covered services. They only pay after
Medicare, employer group health plans, and/or Medigap have paid.
If you have other insurance,tell your doctor, hospital, and pharmacy. If you have questions about
who pays first, or you need to update your other insurance information, call Customer Service
(phone numbers are printed on the back of your member ID card). You may need to give your
plan member ID number to your other insurers (once you have confirmed their identity) so your
bills are paid correctly and on time.
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Chapter 2. Important phone numbers and resources 16❑
Chapter 2. Important phone numbers and resources
SECTION 1 Aetna Medicare Plan contacts (how to contact us, including how to reach
CustomerService at the plan)............................................................................. 17
SECTION 2 Medicare (how to get help and information directly from the federal
Medicareprogram).............................................................................................22
SECTION 3 State Health Insurance Assistance Program (free help, information, and
answers to your questions about Medicare).........................................................23
SECTION 4 Quality Improvement Organization (paid by Medicare to check on the
qualityof care for people with Medicare)...........................................................23
SECTION 5 Social Security..................................................................................................24
SECTION 6 Medicaid (a joint federal and state program that helps with medical costs for
somepeople with limited income and resources)................................................25
SECTION 7 Information about programs to help people pay for their prescription
drugs .................................................................................................................25
SECTION 8 How to contact the Railroad Retirement Board..............................................29
SECTION 9 Do you have"group insurance" or other health insurance from another
employer/union/trust plan?..............................................................................29
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Chapter 2. Important phone numbers and resources 17❑
SECTION 1 Aetna Medicare Plan contacts
(how to contact us, including how to reach Customer
Service at the plan)
How to contact our plan's Customer Service
For assistance with claims, billing or member card questions, please call or write to Aetna
Medicare Plan Customer Service. We will be happy to help you.
Method Customer Service—Contact Information ^
CALL Please call the telephone number printed on the back of your member
ID card or our general customer service center at 1-855-660-1810.
Calls to this number are toll free. We're available 8 a.m.to 6 p.m. local
time,Monday through Friday.
Customer Service also has free language interpreter services available
for non-English speakers.
TTY 711
Calls to this number are toll free. We're available 8 a.m. to 6 p.m. local
time, Monday through Friday.
WRITE
Aetna Medicare
P.O. Box 14088
Lexington,KY 40512-4088
t
WEBSITE http://www.aetnaretireeplans.com
How to contact us when you are asking for a coverage decision about your medical care
A coverage decision is a decision we make about your benefits and coverage or about the amount
we will pay for your medical services. For more information on asking for coverage decisions
about your medical care, see Chapter 9 (What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)).
You may call us if you have questions about our coverage decision process.
Method Coverage Decisions for Medical Care—Contact Information
!} CALL Please call the telephone number printed on the back of your member
ID card or our general customer service center at 1-888-267-2637.
Calls to this number are toll free. We're available 8 a.m.to 6 p.m. local i
time, Monday through Friday. }
E.
Customer Service also has free language interpreter services available
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Chapter 2. Important phone numbers and resources 18❑
Method Coverage Decisions for Medical Care—Contact Information
for non-English speakers.
TTY 711
Calls to this number are toll free. We're available 8 a.m. to 6 p.m. local
time, Monday through Friday.
FAX Please use the following fax number to submit expedited(fast)requests
only: 1-860-754-5468
WRITE Aetna Medicare Precertification Unit
P.O. Box 14079
Lexington,KY 40512-4079
How to contact us when you are making an appeal about your medical care
An appeal is a formal way of asking us to review and change a coverage decision we have made.
For more information on making an appeal about your medical care, see Chapter 9 (What to do if
you have a problem or complaint(coverage decisions, appeals, complaints)).
MethodAppeals for Medical Care—Contact Information
r' CALL 1-800-932-2159 for Expedited Appeals Only
Calls to this number are toll free. We're available 7 days per week,
8 a.m. to 8 p.m. local time.
' TTY 711
Calls to this number are toll free. We're available 7 days per week,
8 a.m.to 8 p.m. local time.
FAX 1-860-907-3984
1�
WRITE Aetna Medicare Grievance &Appeal Unit
P.O. Box 14067
Lexington, KY 40512
AETNA You can submit an appeal about our plan online. To submit an online appeal go
WEBSITE to
http://www.aetnamedicare.com/plan choices/advantage_appeals_grievances.jsp ,
How to contact us when you are making a complaint about your medical care
You can make a complaint about us or one of our network providers, including a complaint
about the quality of your care. This type of complaint does not involve coverage or payment
disputes. (If you have a problem about the plan's coverage or payment, you should look at the
section above about making an appeal.) For more information on making a complaint about your
medical care, see Chapter 9 (What to do if you have a problem or complaint(coverage decisions,
appeals, complaints)).
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Chapter 2. Important phone numbers and resources 19❑
Method Complaints about Medical Care—Contact Information
CALL Please call the telephone number printed on the back of your member ID
card or our general customer service center at 1-888-267-2637.
Calls to this number are toll free. We're available 8 a.m. to 6 p.m. local time,
Monday through Friday.
" TTY 711
Calls to this number are toll free. We're available 8 a.m. to 6 p.m. local time,
Monday through Friday.
FAX 1-866-604-7092
WRITE Aetna Medicare Grievance &Appeal Unit
P.O. Box 14067 �#
Lexington,ICY 40512
AETNA You can submit a complaint about our plan online. To submit an online
WEBSITE
complaint go to
http://www.aetnamedicare.com/plan_choices/advantage_appeals
_grievances.Isp
MEDICARE
You can submit a complaint about our plan directly to Medicare. To submit an
WEBSITE
online complaint to Medicare go to
http://www.medicare.gov/MedicareComplaintForm/home.aspx
How to contact us when you are asking for a coverage decision about your Part D
prescription drugs
A coverage decision is a decision we make about your benefits and coverage or about the amount
we will pay for your Part D prescription drugs. For more information on asking for coverage
decisions about your Part D prescription drugs, see Chapter 9 (What to do if you have a problem
or complaint(coverage decisions, appeals, complaints)).
Method Coverage Decisions for Part D Prescription Drugs—Contact
Information
CALL 1-800-414-2386
Calls to this number are toll free. We're available 8 a.m. to 8 p.m. Eastern
time, 7 days a week.
i; TTY 711
i3
Calls to this number are toll free. We're available 8 a.m.to 8 p.m. Eastern
time, 7 days a week.
FAX 1-800-408-2386
4 r.
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Chapter 2. Important phone numbers and resources 20❑
Method Coverage Decisions for Part D Prescription Drugs—Contact
Information
WRITE Pharmacy Management Precertification Unit
300 Highway 169 South, Suite 5001
Minneapolis, MN 55426
,' WEBSITE
http://www.aetnaretireeplans.com
How to contact us when you are making an appeal about your Part D prescription drugs
An appeal is a formal way of asking us to review and change a coverage decision we have made.
For more information on malting an appeal about your Part D prescription drugs, see Chapter 9
(What to do if you have a problem or complaint(coverage decisions, appeals, complaints)).
Method Appeals for Part D Prescription Drugs—Contact Information
CALL 1-877-235-3755 for Expedited Appeals Only
Calls to this number are toll free. We're available 8 a.m.to 8 p.m. local time,
7 days a week. {
TTY 711
Calls to this number are toll free. We're available 8 a.m.to 8 p.m. local time,
7 days a weep.
FAX 1-866-604-7092
1
WRITE Aetna Medicare Pharmacy Grievance and Appeals Unit
P.O. Box 14579
Lexington, KY 40512
WEBSITE You can submit an appeal online. To submit an online appeal go to
http://www.aetnamedicare.com/plan_choices/advantage_appeals_grievances.jsp
How to contact us when you are making a complaint about your Part D prescription drugs
You can make a complaint about us or one of our network pharmacies, including a complaint
about the quality of your care. This type of complaint does not involve coverage or payment
disputes. (If your problem is about the plan's coverage or payment, you should loop at the
section above about making an appeal.) For more information on malting a complaint about your
Part D prescription drugs, see Chapter 9 (What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)).
Method Complaints about Part D prescription drugs—ContactInformation
CALL Please call the telephone number printed on the back of your member ID card
or our customer service center at 1-800-594-9390.
i Calls to this number are toll free. We're available 8 a.m. to 6 p.m. local time,
Monday through Friday.
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Chapter 2. Important phone numbers and resources 21❑
ryMethod Complaints about PartDn r . -
prescription dru s Contact Information '
TTY 711
Calls to this number are toll free. We're available 8 a.m.to 6 p.m. local time, s
Monday through Friday.
FAX 1-866-604-7092
WRITE . . Aetna
Medicare Pharmacy Grievance and Appeal Unit
P.O. Box 14579
Lexington, KY 40512
AF
TNA You can submit a complaint about our plan online. To submit an online
WEBSITE complaint go to
http://www.aetnamedicare.com/plan choices/advantage_appeals_grievancesj sp
MEDICARE You can submit a complaint about our plan directly to Medicare. To submit an
WEBSITE online complaint to Medicare go to
http://www.medicare.gov/MedicareComplaintForm/home.aspx.
Where to send a request asking us to pay for our share of the cost for medical care or a
drug you have received
For more information on situations in which you may need to ask us for reimbursement or to pay
a bill you have received from a provider, see Chapter 7 (Asking us to pay our share of a bill you
have received for covered medical services or drugs).
Please note: If you send us a payment request and we deny any part of your request, you can
appeal our decision. See Chapter 9 (What to do if you have a problem or complaint (coverage
decisions, appeals, complaints)) for more information.
Method Payment Request—Contact Information
WRITE For Prescription Drug Claims:
Aetna Medicare Prescription Drug Claim Processing Unit
P.O. Box 14023
Lexington, KY 40512-4023
4
f For Medical Claims:
Aetna
P.O. Box 981106 E
El Paso, TX 79998-1106
:
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Chapter 2. Important phone numbers and resources 220
SECTION 2 Medicare
(how to get help and information directly from the federal
Medicare program)
Medicare is the federal health insurance program for people 65 years of age or older, some
people under age 65 with disabilities, and people with End-Stage Renal Disease (permanent
kidney failure requiring dialysis or a kidney transplant).
The federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services
(sometimes called "CMS"). This agency contracts with Medicare Advantage organizations
including us.
Method Medicare—Contact Information
CALL 1-800-MEDICARE, or 1-800-633-4227
Calls to this number are free.
24 hours a day, 7 days a week.
3
TTY 1-877-486-2048
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are free.
WEBSITE http://www.medicare.gov
This is the official government website for Medicare. It gives you up-to-
date information about Medicare and current Medicare issues. It also
has information about hospitals, nursing homes,physicians, home health
agencies, and dialysis facilities. It includes booklets you can print
directly from your computer. You can also find Medicare contacts in
your state.
The Medicare website also has detailed information about your
Medicare eligibility and enrollment options with the following tools:
k
• Medicare Eligibility Tool: Provides Medicare eligibility status
information.
Medicare Plan Finder: Provides personalized information k
r about available Medicare prescription drug plans,Medicare
health plans, and Medigap (Medicare Supplement Insurance)
policies in your area. These tools provide an estimate of what
your out-of-pocket costs might be in different Medicare plans.
You can also use the website to tell Medicare about any complaints you
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Chapter 2. Important phone numbers and resources 23❑
Method Medicare-Contact Information
3
have about our plan:
g
Tell Medicare about your complaint: You can submit a
complaint about our plan directly to Medicare. To submit a
complaint to Medicare, go to http://www.medicare.gov/
s
MedicareComplaintForm/home.aspx. Medicare takes your
complaints seriously and will use this information to help
improve the quality of the Medicare program.
If you don't have a computer, your local library or senior center may be
able to help you visit this website using its computer. Or, you can call
Medicare and tell them what information you are looking for. They will :E
find the information on the website,print it out, and send it to you. (You `
can call Medicare at 1-800-MEDICARE (1-800-633-4227),24 hours a
day, 7 days a week. TTY users should call 1-877-486-2048.)
SECTION 3 State Health Insurance Assistance Program
(free help, information, and answers to your questions
about Medicare)
The State Health Insurance Assistance Program (SHIP) is a government program with trained
counselors in every state. Refer to Addendum A at the back of this Evidence of Coverage for the
name of the State Health Insurance Assistance Program in your state.
A SHIP is independent (not connected with any insurance company or health plan). It is a state
program that gets money from the federal government to give free local health insurance
counseling to people with Medicare.
SHIP counselors can help you with your Medicare questions or problems. They can help you
understand your Medicare rights, help you make complaints about your medical care or
treatment, and help you straighten out problems with your Medicare bills. SHIP counselors can
also help you understand your Medicare plan choices and answer questions about switching
plans.
SECTION 4 Quality Improvement Organization
(paid by Medicare to check on the quality of care for people
with Medicare)
There is a Quality Improvement Organization for each state. Refer to Addendum A at the back of
this Evidence of Coverage for the name of the Quality Improvement Organization in your state.
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A QIO has a group of doctors and other health care professionals who are paid by the federal
government. This organization is paid by Medicare to check on and help improve the quality of
care for people with Medicare. A QIO is an independent organization. It is not connected with
our plan.
You should contact the QIO in your state in any of these situations:
• You have a complaint about the quality of care you have received.
• You think coverage for your hospital stay is ending too soon.
• You think coverage for your home health care, skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.
SECTION 5 Social Security
Social Security is responsible for determining eligibility and handling enrollment for Medicare.
U.S. citizens who are 65 or older, or who have a disability or End-Stage Renal Disease and meet
certain conditions, are eligible for Medicare. If you are already getting Social Security checks,
enrollment into Medicare is automatic. If you are not getting Social Security checks, you have to
enroll in Medicare. Social Security handles the enrollment process for Medicare. To apply for
Medicare, you can call Social Security or visit your local Social Security office.
Social Security is also responsible for determining who has to pay an extra amount for their Part
D drug coverage because they have a higher income. If you got a letter from Social Security
telling you that you have to pay the extra amount and have questions about the amount or if your
income went down because of a life-changing event, you can call Social Security to ask for a
reconsideration.
If you move or change your mailing address, it is important that you contact Social Security to
let them know.
E MethodSocial Security—Contact Information
CALL 1-800...-772-1213
Calls to this number are free.
Available 7:00 a.m. to 7:00p m., Monday through Friday.
You can use Social Security's automated telephone services to get
recorded information and conduct some business 24 hours a day.
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Chapter 2. Important phone numbers and resources 25❑
Method Social Security Contact Information
TTY 1-800-325-0778
t This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are free.
Available 7:00 a.m. to 7:00 p.m., Monday through Friday. {
WEBSITE http://www.ssa.gov
SECTION 6 Medicaid
(a joint federal and state program that helps with medical
costs for some people with limited income and resources)
Medicaid is a joint federal and state government program that helps with medical costs for
certain people with limited incomes and resources. Some people with Medicare are also eligible
for Medicaid.
In addition, there are programs offered through Medicaid that help people with Medicare pay
their Medicare costs, such as their Medicare premiums. These "Medicare Savings Programs"
help people with limited income and resources save money each year:
• Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B
premiums, and other cost-sharing (like deductibles, coinsurance, and copayments). (Some
people with QMB are also eligible for full Medicaid benefits (QMB+).)
• Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums.
(Some people with SLMB are also eligible for full Medicaid benefits (SLMB+).)
• Qualified Individual (QI): Helps pay Part B premiums.
• Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums.
To find out more about Medicaid and its programs, contact your state Medicaid agency. Contact
information is in Addendum A in the back of this Evidence of Coverage.
SECTION 7 Information about programs to help people pay for their
prescription drugs
Medicare's "Extra Help"Program
Medicare provides "Extra Help" to pay prescription drug costs for people who have limited
income and resources. Resources include your savings and stocks, but not your home or car. If
you qualify, you get help paying for any Medicare drug plan's monthly premium, yearly
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deductible, and prescription copayments. This "Extra Help" also counts toward your out-of-
pocket costs.
People with limited income and resources may qualify for "Extra Help." Some people
automatically qualify for"Extra Help" and don't need to apply. Medicare mails a letter to people
who automatically qualify for"Extra Help."
You may be able to get "Extra Help" to pay for your prescription drug premiums and costs. To
see if you qualify for getting"Extra Help," call:
• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours
a day, 7 days a week;
• The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through
Friday. TTY users should call 1-800-325-0778 (applications); or
• Your State Medicaid Office (applications). (See Section 6 of this chapter for contact
information.)
If you believe you have qualified for "Extra Help" and you believe that you are paying an
incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has
established a process that allows you to either request assistance in obtaining evidence of your
proper copayment level, or, if you already have the evidence, to provide this evidence to us.
• While you are at the pharmacy, you can ask the pharmacist to contact Aetna at the
number on your ID card. If the situation cannot be resolved at that time, Aetna will give
you a one-time exception and you will be charged the copayment/coinsurance amount
that you were given by CMS. This exception is temporary and lasts 21 days. Aetna will
permanently update our systems upon the receipt of one of the acceptable forms of
evidence listed below.
You can fax your evidence to Aetna at 1-888-665-6296, or mail your documentation to:
Aetna Medicare Department
Attention: BAE
P.O. Box 14088
Lexington, KY 40512-4088
Examples of evidence can be any of the following items:
• A copy of your Medicaid card that includes your name and an eligibility date during a
month after June of the previous calendar year
• A copy of a state document that confirms active Medicaid status during a month after
June of the previous calendar year
• A print out from the state electronic enrollment file showing Medicaid status during a
month after June of the previous calendar year
• A screen print from the state's Medicaid systems showing Medicaid status during a
month after June of the previous calendar year
• Other documentation provided by the state showing Medicaid status during a month after
June of the previous calendar year
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• For individuals who are not deemed eligible, but who apply and are found LIS eligible, a
copy of the SSA award letter
• If you are institutionalized and qualify for zero cost-sharing:
o A remittance from the facility showing Medicaid payment for a full calendar
month for that individual during a month after June of the previous calendar year
o A copy of a state document that confirms Medicaid payment on your behalf to the
facility for a full calendar month after June of the previous calendar year
o A screen print from the state's Medicaid systems showing your institutional status
based on at least a full calendar month stay for Medicaid payment purposes
during a month after June of the previous calendar year
• CMS and additional SSA documents that supports a beneficiary's LIS cost-sharing level:
o Deeming notice—pub.no. 11166 (purple notice)
o Auto-enrollment notice—pub.no.11154 (yellow notice)
o Full-facilitated notice—pub.no. 11186 (green notice)
o Partial-facilitated notice—pub.no.11191 (green notice)
o Copay change notice—pub.no.11199 (orange notice)
o Reassignment notice—pub.no. 11208 and 11209 (blue notice)
• When we receive the evidence showing your copayment level, we will update our system
so that you can pay the correct copayment when you get your next prescription at the
pharmacy. If you overpay your copayment, we will reimburse you. Either we will
forward a check to you in the amount of your overpayment or we will offset future
copayments. If the pharmacy hasn't collected a copayment from you and is carrying your
copayment as a debt owed by you,we may make the payment directly to the pharmacy. If
a state paid on your behalf, we may make payment directly to the state. Please contact
Customer Service if you have questions (phone numbers are printed on the back of your
member ID card).
Medicare Coverage Gap Discount Program
The Medicare Coverage Gap Discount Program is available nationwide. If your Aetna Medicare
plan offers additional gap coverage during the Coverage Gap Stage,your out-of-pocket costs will
sometimes be lower than the costs described here. Please go to Chapter 6, Section 6 for more
information about your coverage during the Coverage Gap Stage.
The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name
drugs to Part D enrollees who have reached the coverage gap and are not already receiving
"Extra Help."A 50% discount on the negotiated price (excluding the dispensing fee and vaccine
administration fee, if any) is available for those brand name drugs from manufacturers that have
agreed to pay the discount. The plan pays an additional 5% and you pay the remaining 45% for
your brand drugs.
If you reach the coverage gap, we will automatically apply the discount when your pharmacy
bills you for your prescription and your Part D Explanation of Benefits (Part D EOB) will show
any discount provided. Both the amount you pay and the amount discounted by the manufacturer
count toward your out-of-pocket costs as if you had paid them and move you through the
coverage gap. The amount paid by the plan(5%) does not count toward your out-of-pocket costs.
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You also receive some coverage for generic drugs. If you reach the coverage gap, the plan pays
35% of the price for generic drugs and you pay the remaining 65% of the price. The coverage for
generic drugs works differently than the coverage for brand name drugs. For generic drugs, the
amount paid by the plan (35%) does not count toward your out-of-pocket costs. Only the amount
you pay counts and moves you through the coverage gap. Also, the dispensing fee is included as
part of the cost of the drug.
If you have any questions about the availability of discounts for the drugs you are taking or about
the Medicare Coverage Gap Discount Program in general, please contact Customer Service
(phone numbers are printed on the back of your member ID card).
What if you have coverage from a State Pharmaceutical Assistance Program (SPAP)?
If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program
that provides coverage for Part D drugs (other than "Extra Help"), you still get the 50% discount
on covered brand name drugs. Also, the plan pays 5% of the costs of brand drugs in the coverage
gap. The 50% discount and the 5% paid by the plan are applied to the price of the drug before
any SPAP or other coverage.
What if you have coverage from an AIDS Drug Assistance Program (ADAP)?
What is the AIDS Drug Assistance Program (ADAP)?
The AIDS Drug Assistance Program (ADAP) helps ADAP-eligible individuals living with
HIV/AIDS have access to life-saving HIV medications. Medicare Part D prescription drugs that
are also covered by ADAP qualify for prescription cost-sharing assistance. The name of your
state ADAP is shown on Addendum A attached to this Evidence of Coverage. Note: To be
eligible for the ADAP operating in your state, individuals must meet certain criteria, including
proof of state residence and HIV status, low income as defined by the state, and uninsured/under-
insured status.
If you are currently enrolled in an ADAP, it can continue to provide you with Medicare Part D
prescription cost-sharing assistance for drugs on the ADAP formulary. In order to be sure you
continue receiving this assistance, please notify your local ADAP enrollment worker of any
changes in your Medicare Part D plan name or policy number. Contact information for your state
ADAP is shown on Addendum A attached to this Evidence of Coverage.
What if you get "Extra Help" from Medicare to help pay your prescription drug costs?
Can you get the discounts?
No. If you get"Extra Help," you already get coverage for your prescription drug costs during the
coverage gap.
What if you don't get a discount, and you think you should have?
If you think that you have reached the coverage gap and did not get a discount when you paid for
your brand name drug, you should review your next Part D Explanation of Benefits (Part D
EOB) notice. If the discount doesn't appear on your Part D Explanation of Benefits, you should
contact us to make sure that your prescription records are correct and up-to-date. If we don't
agree that you are owed a discount, you can appeal. You can get help filing an appeal from your
State Health Insurance Assistance Program (SHIP) (telephone numbers are in Addendum A at
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the end of this Evidence of Coverage) or by calling 1-800-MEDICARE (1-800-633-4227), 24
hours a day, 7 days a week. TTY users should call 1-877-486-2048.
State Pharmaceutical Assistance Programs
Many states have State Pharmaceutical Assistance Programs that help some people pay for
prescription drugs based on financial need, age, or medical condition. Each state has different
rules to provide drug coverage to its members.
These programs provide limited income and medically needy seniors and individuals with
disabilities financial help for prescription drugs. Refer to Addendum A at the back of this
Evidence of Coverage to identify if there is an SPAP in your state.
SECTION 8 How to contact the Railroad Retirement Board
The Railroad Retirement Board is an independent federal agency that administers comprehensive
benefit programs for the nation's railroad workers and their families. If you have questions
regarding your benefits from the Railroad Retirement Board, contact the agency.
If you receive your Medicare through the Railroad Retirement Board, it is important that you let
them know if you move or change your mailing address.
Method Railroad Retirement Board—Contact Information
CALL 1-877-772-5772
Calls to this number are free.
Available 9:00 am to 3:30 pm, Monday through Friday
If you have a touch-tone telephone, recorded information and automated K
services are available 24 hours a day, including weekends and holidays.
TTY 1-312-751-4701
This number requires special telephone equipment and is only for people
who have difficulties with hearing or speaking.
Calls to this number are not free.
WEBSITE http://www.rrb.gov
SECTION 9 Do you have "group insurance" or other health insurance
from another employer/union/trust plan?
You (or your spouse) get benefits from your (or your spouse's) employer or retiree group. Call
the employer/union benefits administrator or Customer Service if you have any questions. You
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can ask about your (or your spouse's) employer or retiree health benefits, premiums, or the
enrollment period. (Phone numbers for Customer Service are printed on the back of your
member ID card.) You may also call 1-800-MEDICARE (1-800-633-4227; TTY: 1-877-486-
2048)with questions related to your Medicare coverage under this plan.
If you have other prescription drug coverage through your (or your spouse's) employer or retiree
group, please contact that group's benefits administrator. The benefits administrator can help
you determine how your current prescription drug coverage will work,with our plan.
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Chapter 3. Using the plan's coverage for your medical services
SECTION 1 Things to know about getting your medical care covered as a member of
ourplan.............................................................................................................32
Section 1.1 What are "network providers" and"covered services"?............... 32
Section 1.2 Basic rules for getting your medical care covered by the plan...... 32
SECTION 2 Using network and out-of-network providers to get your medical care.........33
Section 2.1 You may choose a Primary Care Provider(PCP)to provide and
oversee your medical care ........................................................... 33
Section 2.2 How to get care from specialists and other network providers...... 34
Section 2.3 How to get care from out-of-network providers........................... 35
SECTION 3 How to get covered services when you have an emergency or urgent need
forcare..............................................................................................................36
Section 3.1 Getting care if you have a medical emergency............................. 36
Section 3.2 Getting care when you have an urgent need for care.................... 37
SECTION 4 What if you are billed directly for the full cost of your covered services?.....38
Section 4.1 You can ask us to pay our share of the cost of covered services... 38
Section 4.2 If services are not covered by our plan, you must pay the full
cost ............................................................................................. 38
SECTION 5 How are your medical services covered when you are in a "clinical
researchstudy"?...............................................................................................38
Section 5.1 What is a"clinical research study"?............................................. 38
Section 5.2 When you participate in a clinical research study,who pays for
what?........................................................................................... 39
SECTION 6 Rules for getting care covered in a "religious non-medical health care
institution"........................................................................................................40
Section 6.1 What is a religious non-medical health care institution?...............40
Section 6.2 What care from a religious non-medical health care institution
is covered by our plan?................................................................41
SECTION 7 Rules for ownership of durable medical equipment....................................... 41
Section 7.1 Will you own the durable medical equipment after malting a
certain number of payments under our plan?................................41
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SECTION 1 Things to know about getting your medical care covered as
a member of our plan
This chapter explains what you need to know about using the plan to get your medical care
coverage. It gives definitions of terms and explains the rules you will need to follow to get the
medical treatments, services, and other medical care that are covered by the plan.
For the details on what medical care is covered by our plan and how much you pay when you get
this care, use the benefits chart included with this Evidence of Coverage. It's described in
Chapter 4 (Medical Benefits Chart, what is covered and what you pay). This benefits chart is
also referred to as Aetna's Schedule of Copayments/Coinsurance.
Section 1.1 What are "network providers" and "covered services"?
Here are some definitions that can help you understand how you get the care and services that
are covered for you as a member of our plan:
• "Providers" are doctors and other health care professionals licensed by the state to
provide medical services and care. The term"providers" also includes hospitals and other
health care facilities.
• "Network providers" are the doctors and other health care professionals, medical
groups, hospitals, and other health care facilities that have an agreement with us to accept
our payment and your cost-sharing amount as payment in full. We have arranged for
these providers to deliver covered services to members in our plan. The providers in our
network generally bill us directly for care they give you. When you see a network
provider, you usually pay only your share of the cost for their services.
• "Covered services" include all the medical care, health care services, supplies, and
equipment that are covered by our plan. Your covered services for medical care are listed
in the benefits chart described in Chapter 4.
Section 1.2 Basic rules for getting your medical care covered by the plan
As a Medicare health plan, our plan must cover all services covered by Original Medicare and
must follow Original Medicare's coverage rules.
Our plan will generally cover your medical care as long as:
• The care you receive is included in the plan's Medical Benefits Chart (Schedule of
Copayments/Coinsurance) included with this Evidence of Coverage).
• The care you receive is considered medically necessary. "Medically necessary" means
that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment
of your medical condition and meet accepted standards of medical practice.
• You receive your care from a provider who is eligible to provide services under
Original Medicare. As a member of our plan, you can receive your care from either a
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network provider or an out-of-network provider(for more about this, see Section 2 in this
chapter).
o The providers in our network are listed in the Provider Directory.
o Please note: While you can get your care from an out-of-network provider, the
provider must be eligible to participate in Medicare and willing to accept our plan.
Except for emergency care, we cannot pay a provider who is not eligible to
participate in Medicare. If you go to a provider who is not eligible to participate in
Medicare, you will be responsible for the full cost of the services you receive.
Check with your provider before receiving services to confirm that they are
eligible to participate in Medicare and willing to accept our plan.
SECTION 2 Using network and out-of-network providers to get your
medical care
Section 2.1 You may choose a Primary Care Provider(PCP) to provide and
oversee your medical care
What is a "PCP" and what does the PCP do for you?
When you become a member of our plan, you do not have to choose a plan provider to be your
Primary Care Provider (PCP), however, we encourage you to do so by contacting Customer
Service at the number on your plan membership card and designating your choice of a PCP. By
having a PCP coordinate your care, you benefit from receiving care from a doctor that has a
deeper understanding of your health care needs. A PCP is usually a physician who meets state
requirements and is trained for and skilled in both disease prevention and the diagnosis and
treatment of acute and chronic illnesses. The PCP is the entry point for most of your health care
needs and they collaborate with other health professionals and coordinate your care with the
appropriate specialists.
Depending on where you live,the following types of providers may act as a PCP:
• General Practitioner
Internist
4. Family Practitioner
• Geriatrician
• Physician Assistants (Not available in all states)
• Nurse Practitioners (Not available in all states)
Please refer to your Provider Directory or access our online Provider Directory (DocFind) at
http://www.aetnaretireeplans.com for a complete listing of PCPs in your area.
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What is the role of a PCP in coordinating covered services?
Your PCP will provide most of your care, and when you need more specialized services, they
will coordinate with other providers. They will help you find a specialist and will arrange for
covered services you get as a member of our plan. Some of the services that the PCP will
coordinate include:
• x-rays;
• laboratory tests;
• therapies;
• care from doctors who are specialists;
• hospital admissions;
• follow-up care.
"Coordinating" your services includes checking or consulting with other plan providers about
your care and how it is progressing. Since your PCP will provide and coordinate your medical
care, we recommend that you have your past medical records sent to your PCP's office. In some
cases, your PCP may need to get approval in advance from our Medical Management
Department for certain types of services or tests (this is called getting "prior authorization").
Services and items requiring prior authorization are listed in Chapter 4.
How do you choose your Network PCP?
You may select a network PCP at the time of enrollment or at any other time. You can select
your PCP by using the Provider Directory, by accessing our online Provider Directory
(DocFind) at http://www.aetnaretireeplans.com, or getting help from Customer Service (phone
numbers are on the back of your member ID card).
If there is a particular plan specialist or hospital that you want to use, check first to be sure that
your PCP makes referrals to that specialist, or uses that hospital.
Changing your Network PCP
You may change your PCP for any reason, at any time. Also, it's possible that your PCP might
leave our plan's network of providers and you would have to find a new PCP.
To change your PCP, call Customer Service at the number on the back of your member ID card
before you set up an appointment with a new PCP. When you call, be sure to tell Customer
Service if you are seeing specialists or currently getting other covered services that were
coordinated by your PCP (such as home health services and durable medical equipment). They
will check to see if the PCP you want to switch to is accepting new patients. Customer Service
will change your membership record to show the name of your new PCP, let you know the
effective date of your change request, and answer your questions about the change.
Section 2 2 How to get care from specialists and other network providers
A specialist is a doctor who provides health care services for a specific disease or part of the
body. There are many kinds of specialists. Here are a few examples:
• Oncologists care for patients with cancer.
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• Cardiologists care for patients with heart conditions.
• Orthopedists care for patients with certain bone,joint, or muscle conditions.
As a member of our plan, you don't need to use a PCP to provide a referral. You may go directly
to a network specialist. If you do choose to use a PCP, when your PCP thinks you may need
specialized treatment, your PCP will direct you to see a network plan specialist or other health
care provider or facility.
For certain types of covered services or supplies, your network PCP or other network provider
will need to get prior authorization (prior approval) from Aetna. These covered services are
marked on the Benefits Chart included with this Evidence of Coverage.
What if a specialist or another network provider leaves our plan?
We may make changes to the hospitals, doctors, and specialists (providers) that are part of your
plan during the year. There are a number of reasons why your provider might leave your plan but
if your doctor or specialist does leave your plan you have certain rights and protections that are
summarized below:
• Even though our network of providers may change during the year, Medicare requires
that we furnish you with uninterrupted access to qualified doctors and specialists.
• When possible we will provide you with at least 30 days' notice that your provider is
leaving our plan so that you have time to select a new provider.
• We will assist you in selecting a new qualified provider to continue managing your health
care needs.
• If you are undergoing medical treatment you have the right to request, and we will work
with you to ensure, that the medically necessary treatment you are receiving is not
interrupted.
• If you believe we have not furnished you with a qualified provider to replace your
previous provider or that your care is not being appropriately managed you have the right
to file an appeal of our decision.
• If you find out that your doctor or specialist is leaving your plan please contact us so we
can assist you in finding a new provider and managing your care.
You may contact Customer Service at the number on your ID card for assistance in selecting a
new PCP or to identify other Aetna Medicare participating providers. You may also look up
participating providers using DocFind, available on our website at
http://www.aetnaretireeplans.com.
Section 2.3 How to get care from out-of-networkproviders
As a member of our plan, you can choose to receive care from out-of-network providers. Our
plan will cover services from either in-network or out-of-network providers, as long as the
services are covered benefits and are medically necessary. Here are other important things to
know about using out-of-network providers:
• You can get your care from an out-of-network provider; however, in most cases that
provider must be eligible to participate in Medicare and willing to accept our plan.
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Except for emergency care, we cannot pay a provider who is not eligible to participate in
Medicare. If you receive care from a provider who is not eligible to participate in
Medicare, you will be responsible for the full cost of the services you receive. Check with
your provider before receiving services to confirm that they are eligible to participate in
Medicare and willing to accept our plan.
• You don't need to get a referral or prior authorization when you get care from out-of-
network providers. However, before getting services from out-of-network providers you
may want to ask for a pre-visit coverage decision to confirm that the services you are
getting are covered and are medically necessary. (See Chapter 9, Section 4 for
information about asking for coverage decisions.) This is important because:
o Without a pre-visit coverage decision, if we later determine that the services are
not covered or were not medically necessary,we may deny coverage and you will
be responsible for the entire cost. If we say we will not cover your services, you
have the right to appeal our decision not to cover your care. See Chapter 9 (What
to do if you have a problem or complaint)to learn how to make an appeal.
• It is best to ask an out-of-network provider to bill the plan first. But, if you have already
paid for the covered services, we will reimburse you for our share of the cost for covered
services. Or if an out-of-network provider sends you a bill that you think we should pay,
you can send it to us for payment. See Chapter 7 (Asking us to pay our share of a bill you
have received for covered medical services or drugs) for information about what to do if
you receive a bill or if you need to ask for reimbursement.
SECTION 3 How to get covered services when you have an emergency
or urgent need for care
Section 3.1 Getting care if you have a medical emergency
What is a "medical emergency" and what should you do if you have one?
A "medical emergency" is when you, or any other prudent layperson with an average
knowledge of health and medicine, believe that you have medical symptoms that require
immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb.
The medical symptoms may be an illness, injury, severe pain, or a medical condition that is
quickly getting worse.
If you have a medical emergency:
• Get help as quickly as possible. Call 911 for help or go to the nearest emergency room
or hospital. Call for an ambulance if you need it. You do not need to get approval or a
referral first from your PCP.
• As soon as possible, make sure that our plan has been told about your emergency.
We need to follow up on your emergency care. You or someone else should call to tell us
about your emergency care, usually within 48 hours. Please call Customer Service at the
number on your member ID card.
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What is covered if you have a medical emergency?
You may get covered emergency medical care whenever you need it, anywhere in the United
States or its territories. Our plan covers ambulance services in situations where getting to the
emergency room in any other way could endanger your health. For more information, see the
Medical Benefits Chart included with this Evidence of Coverage.
Our plan also covers emergency medical care if you receive the care outside of the United States.
Please see Chapter 4 for more information.
If you have an emergency, we will talk with the doctors who are giving you emergency care to
help manage and follow up on your care. The doctors who are giving you emergency care will
decide when your condition is stable and the medical emergency is over.
After the emergency is over you are entitled to follow-up care to be sure your condition
continues to be stable. Your follow-up care will be covered by our plan.
What if it wasn't a medical emergency?
Sometimes it can be hard to know if you have a medical emergency. For example, you might go
in for emergency care —thinking that your health is in serious danger — and the doctor may say
that it wasn't a medical emergency after all. If it turns out that it was not an emergency, as long
as you reasonably thought your health was in serious danger,we will cover your care.
In addition, after the doctor has said that it was not an emergency, the amount of cost-sharing
that you pay will be the same whether you get the care from network providers or out-of-network
providers.
Section 3.2 Getting care when you have an urgent need for care
What is "urgently needed care"?
"Urgently needed care" is a non-emergency, unforeseen medical illness, injury, or condition that
requires immediate medical care. Urgently needed care may be furnished by in-network
providers or by out-of-network providers. The unforeseen condition could, for example, be an
unforeseen flare-up of a known condition that you have.
What if you are in the plan's service area when you have an urgent need for care?
Our plan covers urgently needed care you receive from network or out-of-network providers at
the same cost sharing amount.
When circumstances are unusual or extraordinary, proceed to the nearest urgent care center for
immediate treatment.
What if you are outside the plan's service area when you have an urgent need for care?
When you are outside the service area, our plan covers urgently needed care you receive from
network or out-of-network providers at the same cost-sharing amount.
Our plan also covers urgently needed care if you receive the care outside of the United States.
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SECTION 4 What if you are billed directly for the full cost of your
covered services?
Section 4.1 You can ask us to pay our share of the cost of covered services
If you have paid more than your share for covered services, or if you have received a bill for the
full cost of covered medical services, go to Chapter 7 (Asking us to pay our share of a bill you
have received for covered medical services or drugs) for information about what to do.
Section 4.2 If services are not covered by our plan,you must pay the full cost
Our plan covers all medical services that are medically necessary, are listed in the plan's Medical
Benefits Chart (this chart is included with this Evidence of Coverage), and are obtained
consistent with plan rules. You are responsible for paying the full cost of services that aren't
covered by our plan, either because they are not plan covered services, or plan rules were not
followed.
If you have any questions about whether we will pay for any medical service or care that you are
considering, you have the right to ask us whether we will cover it before you get it. If we say we
will not cover your services, you have the right to appeal our decision not to cover your care.
Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)) has more information about what to do if you want a coverage decision from us or
want to appeal a decision we have already made. You may also call Customer Service to get
more information about how to do this (phone numbers are printed on the back of your member
ID card).
For covered services that have a benefit limitation, you pay the full cost of any services you get
after you have used up your benefit for that type of covered service. Paying for costs once a
benefit limit has been reached will not count toward an out-of-pocket maximum limit. You can
call Customer Service when you want to know how much of your benefit limit you have already
used.
SECTION 5 How are your medical services covered when you are in a
"clinical research study"?
Section 5 1 What is a "clinical research study"� �
A clinical research study (also called a "clinical trial") is a way that doctors and scientists test
new types of medical care, like how well a new cancer drug works. They test new medical care
procedures or drugs by asking for volunteers to help with the study. This kind of study is one of
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the final stages of a research process that helps doctors and scientists see if a new approach
works and if it is safe.
Not all clinical research studies are open to members of our plan. Medicare first needs to approve
the research study. If you participate in a study that Medicare has not approved, you will be
responsible for paying all costs for your participation in the study.
Once Medicare approves the study, someone who works on the study will contact you to explain
more about the study and see if you meet the requirements set by the scientists who are running
the study. You can participate in the study as long as you meet the requirements for the study
and you have a full understanding and acceptance of what is involved if you participate in the
study.
If you participate in a Medicare-approved study, Original Medicare pays most of the costs for the
covered services you receive as part of the study. When you are in a clinical research study, you
may stay enrolled in our plan and continue to get the rest of your care (the care that is not related
to the study)through our plan.
If you want to participate in a Medicare-approved clinical research study, you do not need to get
approval fi-om us. The providers that deliver your care as part of the clinical research study do
not need to be part of our plan's network of providers.
Although you do not need to get our plan's permission to be in a clinical research study, you do
need to tell us before you start participating in a clinical research study. Here is why you
need to tell us:
1. We can let you know whether the clinical research study is Medicare-approved.
2. We can tell you what services you will get from clinical research study providers instead
of from our plan.
If you plan on participating in a clinical research study, contact Customer Service (phone
numbers are printed on the back of your member ID card).
Section 5.2 When you participate in a clinical research study,who pays for what?
Once you join a Medicare-approved clinical research study, you are covered for routine items
and set-vices you receive as part of the study, including:
• Room and board for a hospital stay that Medicare would pay for even if you weren't in a
study.
• An operation or other medical procedure if it is part of the research study.
• Treatment of side effects and complications of the new care.
Original Medicare pays most of the cost of the covered services you receive as part of the study.
After Medicare has paid its share of the cost for these services, our plan will also pay for part of
the costs. We will pay the difference between the cost-sharing in Original Medicare and your
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cost-sharing as a member of our plan. This means you will pay the same amount for the services
you receive as part of the study as you would if you received these services from our plan.
Here's an example of how the cost-sharing works: Let's say that you have a lab test that
costs $100 as part of the research study. Let's also say that your share of the costs for this
test is $20 under Original Medicare, but the test would be $10 under our plan's benefits.
In this case, Original Medicare would pay $80 for the test and we would pay another$10.
This means that you would pay $10, which is the same amount you would pay under our
plan's benefits.
In order for us to pay for our share of the costs, you will need to submit a request for payment.
With your request, you will need to send us a copy of your Medicare Summary Notices or other
documentation that shows what services you received as part of the study and how much you
owe. Please see Chapter 7 for more information about submitting requests for payment.
When you are part of a clinical research study, neither Medicare nor our plan will pay for any
of the following:
• Generally, Medicare will not pay for the new item or service that the study is testing
unless Medicare would cover the item or service even if you were not in a study.
• Items and services the study gives you or any participant for free.
• Items or services provided only to collect data, and not used in your direct health care.
For example, Medicare would not pay for monthly CT scans done as part of the study if
your medical condition would normally require only one CT scan.
Do you want to know more?
You can get more information about joining a clinical research study by reading the publication
"Medicare and Clinical Research Studies" on the Medicare website (http://www.medicare.gov).
You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY
users should call 1-877-486-2048.
SECTION 6 Rules for getting care covered in a "religious non-medical
health care institution"
Section 6 1-6.
What is a religious non-medical health care institution?
A religious non-medical health care institution is a facility that provides care for a condition that
would ordinarily be treated in a hospital or skilled nursing facility care. If getting care in a
hospital or a skilled nursing facility is against a member's religious beliefs, we will instead
provide coverage for care in a religious non-medical health care institution. You may choose to
pursue medical care at any time for any reason. This benefit is provided only for Part A inpatient
services (non-medical health care services). Medicare will only pay for non-medical health care
services provided by religious non-medical health care institutions.
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Section 6.2 What care from a religious non-medical health care institution is
covered by our plan?
To get care from a religious non-medical health care institution, you must sign a legal document
that says you are conscientiously opposed to getting medical treatment that is"non-excepted."
• "Non-excepted" medical care or treatment is any medical care or treatment that is
voluntary and not required by any federal, state, or local law.
• "Excepted" medical treatment is medical care or treatment that you get that is not
voluntary or is required under federal, state, or local law.
To be covered by our plan, the care you get from a religious non-medical health care institution
must meet the following conditions:
• The facility providing the care must be certified by Medicare.
• Our plan's coverage of services you receive is limited to non-religious aspects of care.
• If you get services from this institution that are provided to you in your home, our plan
will cover these services only if your condition would ordinarily meet the conditions for
coverage of services given by home health agencies that are not religious non-medical
health care institutions.
• If you get services from this institution that are provided to you in a facility, the
following condition applies:
o You must have a medical condition that would allow you to receive covered
services for inpatient hospital care or skilled nursing facility care.
Medicare Inpatient Hospital coverage limits apply. See the Benefits Chart included with this
Evidence of Coverage.
SECTION 7 Rules for ownership of durable medical equipment
Section 7.1 Will you own the durable medical equipment after making a certain
number of payments under our plan?
Durable medical equipment includes items such as oxygen equipment and supplies,wheelchairs,
walkers, and hospital beds ordered by a provider for use in the home. Certain items, such as
prosthetics, are always owned by the member. In this section, we discuss other types of durable
medical equipment that must be rented.
In Original Medicare, people who rent certain types of durable medical equipment own the
equipment after paying copayments for the item for 13 months. As a member of our plan, we
will transfer ownership of certain durable medical equipment items. Call Customer Service
(phone numbers are printed on the back cover of this booklet) to find out about the requirements
you must meet and the documentation you need to provide.
EGWP CCP D2 2015 ESA PPO EOC-with Rx(Y2015)
2015 Evidence of Coverage for Aetna MedicaresM Plan (PPO)
Chapter 3. Using the plan's coverage for your medical services 42
What happens to payments you have made for durable medical equipment if you switch to
Original Medicare?
If you switch to Original Medicare after being a member of our plan: If you did not acquire
ownership of the durable medical equipment item while in our plan, you will have to make 13
new consecutive payments for the item while in Original Medicare in order to acquire ownership
of the item. Your previous payments while in our plan do not count toward these 13 consecutive
payments.
If you made payments for the durable medical equipment item under Original Medicare before
you joined our plan,these previous Original Medicare payments also do not count toward the 13
consecutive payments. You will have to make 13 consecutive payments for the item under
Original Medicare in order to acquire ownership. There are no exceptions to this case when you
return to Original Medicare.
EGWP CCP D2 2015 ESA PPO EOC-with Rx(Y2015)