Small Business Solutions - Health, Dental, Vision, Pharmacy, Life and Disability New Jersey
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Health, Dental, Small Business Solutions Vision, Pharmacy, Life and Disability New Jersey FOR BUSINESSES WITH 2 – 50 ELIGIBLE EMPLOYEES 14.02.922.1-NJ (2/05)
Recently there’s been significant publicity about “consumer-directed” health plans. At Aetna, we believe these plans are defined by putting consumers in the center of the health care equation, with the insur- er and health care practitioner play- ing the supporting roles. Consumer-directed plans increase flexibility, control and choice for the employer and the employee. Aetna recognizes the challenges of rising healthcare costs and the demands of running a successful small business. We are working with small businesses to establish innovative, realistic and practical ways to continue providing quality coverage at affordable prices. At Aetna Small Group*, we are bet- ting heavily on the consumer, which is why we offer easy-to-understand, flexible, affordable consumer choice plans. We’re committed to investing in tools, education and technology to help consumers make clear, informed decisions. Bill Roth, Senior Vice President Aetna Small Group Our portfolio of health, dental, vision, pharmacy, life and disability insurance products is designed to help your employees stay healthy and productive through all stages of life. *Aetna Small Group refers to an internal business unit of Aetna.
Choice. Simplicity. Affordability. With Aetna. It’s Yours. Our portfolio of health, dental, pharmacy, life and disability In the world of small business, products is designed to help your employees stay healthy and there’s nothing more critical to your productive through all stages company’s success than the health of life. From the National Medical Excellence and well-being of your employees. Program®, our transplant and complex At Aetna*, we are committed to care program, to our disease manage- ment and vision programs, Aetna offers putting the member at the center solutions for your small business. of everything we do — with a new *The Aetna companies that offer, underwrite or generation of consumer-friendly administer benefits coverage include Aetna Health Inc., Aetna Life Insurance Company and/or Aetna Dental Inc. For the Aetna Golden health care benefits and related Choice Plan, Corporate Health Insurance Company also offers, underwrites or adminis- ters benefits. programs designed to give your employees the product choices, tools and information they need to lead healthier, more productive lives. Technology Solutions 3 Special Programs 4 Provider Networks 5 Product Overview 6-8 Dental Plans 9-11 Life and Disability 12-15 Limitations and Exclusions 16
Designed with small Choice. Simplicity. Affordability. businesses in mind, Aetna is proud to offer its Aetna With Aetna. It’s Yours. Product Suite, providing choice, simplicity and affordability. Aetna understands small business — Simplicity especially when it comes to the daily challenges of controlling costs, keeping Straightforward and easy-to-understand things simple and providing employee benefits. That’s what Aetna provides to choice in health care benefits. small employers and their employees. Member experiences will be enriched Employers and their employees have through user-friendly technology been depending on Aetna for years. and online tools such as the Aetna Now we’re offering the next generation NavigatorTM self-service website and our of consumer choice products that address DocFind® online provider directory. small business challenges for providing choice, simplicity and affordability. Affordability With Aetna’s consumer choice plan Choice designs, employers and their employees In addition to the standard health bene- now have the option of how much fits plans, Aetna offers health plan to invest in monthly premiums versus designs with a large network for small out-of-pocket expenses. This puts employers in New Jersey. Employers can consumers in the center of the health now empower employees by giving them care equation. a choice in their health care benefits and freedom that aligns with their individual lifestyles. 2
Technology Solutions zip code, miles willing to travel, city and state, or county and state. Narrow the search by specialty, hospital affiliation and/or languages spoken — all with a few clicks of a mouse. When members find the provider they want, we can also help them get there with a map and driving directions from Maps On Us®. Best of all, DocFind is updated regularly and is available 24 hours a day, 7 days a week. To request a paper directory, contact your broker or Aetna. Through Aetna’s website Aetna InteliHealth® Website (www.aetna.com) ■ Research the price of a drug and learn if members have access there are less-costly alternatives.* Our award-winning health information to health information website, www.intelihealth.com, is a pre- ■ Find health care professionals and resources and services mier provider of online consumer-based facilities that participate in their plan. designed to help them health, wellness and disease-specific infor- better manage their health. ■ Request member ID cards. mation. In addition, members can search a drug database and register for condi- ■ Print temporary member identification tion-specific e-mails. information needed for a health care visit. ■ View the latest health information and Aetna Voice Advantage® news, and more! The system enables employees to conduct many tasks by phone, such as Estimate the Cost of Care Tools checking claims, changing doctors and Aetna’s suite of interactive Web-based cost requesting ID cards. tools is designed to help members estimate Aetna Navigator™ — The the costs of health care services so they can Plan for Your Health Power to Help Members plan for and take better charge of their Manage Their Health health care expenses. Members have access Plan for Your Health is a public education campaign focused on It’s easy and convenient for Aetna to cost estimates for medical procedures, helping consumers understand the members to manage their health bene- office visits, medical tests, and diseases and connection between health benefits fits. Anytime — day or night — wher- conditions. They may also have access and financial planning — particularly ever they have Internet access, mem- to two other cost tools depending on their for women. The campaign’s website, bers can log in to Aetna Navigator, Aetna coverage. Members enrolled in an PlanforYourHealth.com, makes it easy Aetna’s secure member website. Aetna Dental PPO or PPO Max Plan can for consumers to access credible tools Members who register on the site can access the dental procedures cost tool. and information, empowering them check the status of their claims, con- Those with prescription drug coverage can to make better health benefits and tact Aetna Member Services, estimate use the prescription drugs cost tool. financial decisions to meet their present the costs of health care services, and Aetna Navigator is ready 24/7! Aetna and future needs. The site includes: much more! members can go to www.aetna.com and ■ Useful tips on navigating health Aetna Navigator is a valuable online select Aetna Navigator. If they haven’t benefits in relation to overall resource for personalized benefits and already, encourage them to register today financial well-being. health information. Once registered for by clicking on the Register Now! link. Aetna Navigator, members can: ■ Tools to figure out how important DocFind® life changes will affect health benefits ■ Review who is covered under options. their plan. Finding a participating doctor has never been ■ Information on choosing the best easier with our DocFind online provider ■ Check claim status and view Claim health benefits options for women directory. Members can search Explanation of Benefits (EOB) and their families. for participating physicians, hospitals, phar- statements. macies, dentists and eyewear providers. *If offered by their plan. ■ Estimate the costs of health care DocFind also allows members to search by services to better plan their expenses. 3
Special Programs Check out our website at www.aetna.com today. With just a few clicks, you can receive additional product information, download brochures, and more. Our special programs* offer a wealth Alternative Health Care Programs — Informed Health® Line — members can of features that complement our reduced rates on alternative therapies for get answers to their health questions standard medical and dental members including visits to acupuncturists, anytime … day or night. Our 24-hour, coverage — including substantial chiropractors, massage therapists and toll-free Informed Health Line offers savings on products and educational materials geared toward employees’ nutritional counselors. Save on many access to a team of registered nurses who special health needs. Read on to health-related products, including can provide information on a variety of discover the many ways we can aromatherapy and natural body care, health issues. Members can also listen to help you and your employees through the National Products Program. our audio Health Library, a recorded col- stay healthy. Plus, you can also save on over-the-counter lection of more than 2,000 health topics Fitness Program — members can enjoy vitamins and nutritional supplements in English and Spanish. special membership rates at participating through the Vitamin Advantage™ Healthy Outlook Program® — Our fitness clubs contracted with GlobalFit Program. disease management programs offer and discounts on certain home exercise National Medical Excellence Program® — access to case management, education equipment. Plus, members may even try when Aetna members face difficult or life- and other services for members with out the facility before joining.** threatening situations such as organ trans- chronic health conditions such as Eye Care Savings Program plants, Aetna’s National Medical Excellence asthma, diabetes, chronic heart failure The Vision One®*** discount program Program (NME) coordinates care and pro- and coronary artery disease. gives your employees’ special savings on vides access to covered treatment through Women’s Health Programs — focus eye exams (not covered under your base our Institutes of Excellence™ network. specifically on the health care needs of medical plan), contacts, frames, lenses The program also coordinates specialized women. Programs include: and other eye care accessories. They’ll treatment for members with certain rare or have many locations to choose from, complicated conditions, and assists ■ Our Moms-to-Babies® Maternity such as Sears Optical, JCPenney Optical, members who are admitted to the Management Program, which offers Target Optical, participating Pearle hospital for emergency medical care when information and services to expectant Vision Centers, and other participating they are traveling temporarily mothers including care coordination vision professionals. outside of the United States. Except for by obstetrical nurses experienced in emergency medical care as described above, preterm labor education, breastfeeding Your employees also receive: services under this program must be preau- support and more. ■ A contact lens mail-order replacement thorized. A listing of facilities in our ■ Our Breast Health Education Center, service through Contacts Direct. Institutes of Excellence network can be which offers information and services found in DocFind at www.aetna.com. ■ Discount off the surgeon’s fees for dedicated to breast health, including LASIK eye surgery. Cancer Screening Programs — remind our Breast Cancer Case Management age-eligible HMO and POS members Program, confidential genetic testing ■ 20-percent discount off retail prices on to schedule periodic cancer screenings. for breast and ovarian cancer, our vision-related items when purchased at Reminders are for breast and cervical Breast Health website and more. a Cole Managed Vision provider. cancer screenings, as well as colorectal ■ Infertility case management and ■ Access to Aetna Navigator, our online cancer screenings. education. resource for checking claims status, ordering ID cards and locating eye care *Availability varies by plan. Talk with your Aetna professionals quickly … and easily. representative for details. **Not available at all clubs. ***Vision One is a registered trademark of Cole Managed Vision. 4
Provider Network New Jersey Network* Map Key All plans are available in all New Jersey counties. Contact Information by County Northeast Region Small Group Sales Support Center: 1-888-277-1053 Bergen Monmouth Sussex Essex Morris Union Hudson Ocean Warren Hunterdon Passaic Middlesex Somerset Mid-Atlantic Small Group Sales Support Center: 1-877-28-AETNA Atlantic Cape May Mercer Burlington Cumberland Salem Camden Gloucester *Network subject to change. 5
Product Overview* Aetna Primary Care® Plan HMO Members never need a referral when visiting Aetna Choice® Plan POS — a participating specialist for covered services. No Referrals Members access care through Primary Care Physicians. The Primary Care Plan HMO — No need for referrals; freedom to select With this health benefit plan, members No Referrals provides: provider of choice. ■ Flexibility — there’s no referral needed begin by selecting a Primary Care Aetna Choice POS — No Referrals Physician (PCP) from Aetna’s participating from PCP to visit participating providers. offers all the health plan benefits of a network of providers. A member selects a point-of-service plan with two easy ways ■ Emergency care coverage anywhere, PCP who will coordinate their health care to access care when members need it. anytime, 24 hrs a day needs for covered benefits or services. Each Members have the freedom to visit the covered member of the family may choose ■ No claim forms. participating doctor or hospital of their their own PCP. choice for covered services. Best of all, ■ No lifetime dollar maximums. members do not need referrals. This The Primary Care Plan HMO provides: ■ Large provider networks. plan allows members to: ■ Large provider networks. ■ Select and visit their participating ■ Low out-of-pocket costs. Aetna Choice® Plan POS PCP and pay the plan’s copayment ■ No claim forms. Freedom to select providers. for covered benefits. This health benefit plan values the role of ■ Member’s PCP coordinates their ■ Go directly to any network physician the PCP to serve as the coordinator of the covered health care services. from within Aetna’s network of member’s health care. Members seeking providers and pay the applicable spe- ■ Emergency care coverage anywhere, health care have the flexibility to access care cialist copayment for covered benefits. anytime, 24 hrs a day in or out of the network. For this flexibility, self-referring members share more of the ■ Go directly to any licensed out-of- ■ No lifetime dollar maximums. cost of care through a deductible and coin- network physician, subject to payment ■ Referral is required for most services not surance. of a deductible and coinsurance. administered by the PCP and The Aetna Choice Plan POS provides: ■ No lifetime dollar maximums inpatient hospital care. ■ Flexibility to self-refer. in-network. ■ Direct access to some specialists, ■ No lifetime dollar maximums in network. ■ Large provider networks. like Ob/Gyn. ■ Large provider networks. Aetna Primary Care® Plan HMO ■ Member encouraged to choose a PCP from *This is an overview of Aetna’s packaged product offerings and is not intended to be an exhaus- — No Referrals Aetna’s network of participating providers. tive list of plan offerings or options available. Aetna also offers standard health benefit plans Flexibility and no referrals needed in New Jersey. ■ Member visits PCP for routine care or for **A copayment can be either a flat dollar amount for participating providers. injury or illness; member pays applicable or a percentage of covered services. With this health benefit plan, members copay each time covered benefits are may choose how they access covered bene- accessed within the network with PCP fits. Members can visit a PCP and pay a referral. lower copay** or go directly to any partici- pating physician and pay a higher copay. ■ Member may visit any out-of-network licensed provider, without PCP referral for a covered benefit; member shares the 6 cost of care through deductible/coinsurance.
Aetna First Dollar Plan owners that have not offered coverage to provide more health care benefits than their employees in the past, because of the Original Medicare plan. The First Dollar Plan is a high price, now have a plan option that provides deductible PPO insurance plan with a Members access care through Primary basic affordable coverage. special benefit feature allowing a limited Care Physicians. dollar amount of services prior to the NOTE: This plan provides limited benefits Members of the Aetna Golden deductible coming into play. only and does not constitute a comprehen- Medicare Plan must select a network sive health insurance plan. As such, it may primary care doctor to coordinate all Here’s how it works: the First Dollar not cover all the expenses associated with covered care, including: Plan offers the first $500 individ- your health care needs. ual/$1,000 family in covered medical ■ Routine and preventive care. expenses (excludes RX) to be paid at Out-of-State/Situs Employee ■ Treatment of illness and injuries. 100% NOT subject to the deductible. Plan Open Choice® PPO Once the available first dollars funds are ■ Referrals to network specialists and Coverage exhausted, a deductible must be met for facilities for certain services, if all covered medical services (excludes Rx Coverage available only for eligible required. and certain state-mandated benefits). employees who live outside of Other Aetna Golden Medicare Plan Once the deductible is satisfied, the Connecticut, Delaware, Maryland, features include: member will then be responsible for the New Jersey, New York, Pennsylvania, cost sharing amounts as indicated in the Virginia and Washington, D.C. ■ Large networks of doctors and hospitals. plan documents. Open Choice gives members the freedom ■ Referrals to specialist and inpatient to choose any licensed physician or hospital hospital services, if needed. The Basic Hospital Plan whenever they need medical treatment. Whether the member is at home or away, ■ Direct access to some specialists, The Basic Hospital Plan is ideal for like Ob/Gyn. members have access to covered services small business owners that are primarily with no referrals. Members may pay less ■ Low or no monthly premiums. looking for affordability when selecting a out-of-pocket when they visit an in-net- coverage option. This high-deductible ■ Fixed out-of-pocket costs for covered work physician than if they visit a provider insurance plan provides inpatient hospi- services. not in the network. tal coverage coupled with limited bene- ■ No lifetime dollar maximums. fits for outpatient surgery, skilled nurs- The Aetna Golden ing or home health care charges in lieu ■ No copays for select preventive services. Medicare Plan® (HMO) of hospitalization. In addition, this plan ■ Multiple options to save money includes three office visits per member This is a Medicare Advantage HMO plan on prescription drugs. per calendar year for acute and preven- which provides health care benefits for tive care and a fixed benefit allowance Medicare beneficiaries through our con- ■ Worldwide emergency care. for lab and x-ray services. tract with the federal government. When a ■ Access to benefits when traveling to Medicare beneficiary enrolls plan-approved service areas through The deductible on the Basic Hospital in our Medicare Advantage plan, the feder- ® the U.S. Travel Advantage program Plan applies to all covered expenses, al government pays us a set amount of (available in limited service areas). except certain state-mandated benefits, money for their covered care every month. allowed acute/preventive care office visits In return, we manage their Medicare cover- and lab-and x-ray services covered by the age. This funding arrangement allows us to fixed benefit allowance. Small business 7
■ Automatic claims filing when using network doctors and hospitals. Enrollee must be entitled to Medicare Part A and continue to pay the part B premium and Part A, if applicable. Higher costs apply for out-of-network services. Certain services require pre- certification or prior approval of cover- age. Providers must be licensed and eli- gible to receive payment under the fed- eral Medicare program. Coverage is pro- vided through a Medicare Advantage organization with a Medicare contract and benefits, limitations, service areas and premiums are subject to change on ■ Access to preventive health and wellness Members can access care in three January 1 of each year. programs at no additional cost. easy ways: ■ Go directly to any licensed out-of-network Aetna Dental® Plans ■ Toll-free phone and online resources doctor who accepts Medicare for most for instant access to health information. Small business decision makers can covered services, subject to payment of an ■ Money-saving services, including choose from a variety of plan design applicable deductible and coinsurance – reduced-rate eyewear and vitamins. options that help you offer a dental plan no referrals needed! that’s just right for your employees. Aetna ■ Automatic claims filing. ■ Go directly to any in-network physician offers a range of dental benefits plans, Enrollee must be entitled to Medicare and pay the applicable specialist copay – including our Preferred Provider Part A and continue to pay the part B no referrals needed! Organization (PPO) and Dental premium and Part A, if applicable. ■ Go to a primary care doctor and pay the Maintenance Organization (DMO®) Enrollee must use network providers applicable copay. plans. With our dental PPO plans, mem- except for emergency care or out-of-area bers have the option to use a participat- Other Aetna Golden Choice Plan ing network dentist or a licensed dentist urgent care/renal dialysis. Coverage is features include: who is not in the network. With our provided through a Medicare Advantage ■ Flexibility to visit doctors and hospitals in organization with a Medicare contract DMO plans, members select a participat- or out of network. (Certain services are ing primary care dentist who coordinates and benefits, limitations, service areas only available in-network for coverage to their dental care, including referrals to net- and premiums are subject to change on apply). work specialists as needed. Both plans offer January 1 of each year. > Coordinate care through a network members access to large networks of partic- The Aetna Golden Choice™ primary care doctor for fixed copays. ipating dentists and dental specialists. Plan (POS) > Go out of network and pay a low Aetna’s Freedom-of-Choice plan design deductible and coinsurance. offers two plans in one. Your employee This is a Medicare Advantage POS plan ■ Large networks of doctors and hospitals. which provides health care benefits for can choose between the Dental PPO and Medicare beneficiaries through our con- ■ No annual or lifetime dollar maximums the DMO. They can switch between tract with the federal government. When in network. plans each month or stay with the plan a Medicare beneficiary enrolls in the they originally selected … the choice is ■ No copays for select preventive services. always theirs! plan, the federal government pays us a set amount of money for their covered ■ Multiple options to save money on pre- care every month. In return, we manage scription drugs. Aetna Life and Disability their Medicare coverage. This funding Plans ■ Worldwide emergency care. arrangement allows us to provide more Aetna offers a wide range of flat dollar health care benefits than the Original ■ Access to preventive health and wellness insurance options for basic employee Medicare plan. programs at no additional cost. term life insurance as well as disability ■ Toll-free phone and online resources for health plan benefit solutions. Aetna’s instant access to health information. affordable life insurance options enable ■ Money-saving services, including reduced- members to establish financial protec- rate eyewear and vitamins. tion for themselves and their families. Members can also benefit from Aetna’s Packaged Life and Disability product. See pages 12-15 for more details. 8
NEW JERSEY AETNA SMALL GROUP DENTAL PLANS DENTAL PLAN OPTIONS Available With an Aetna Medical Plan (2 – 50 Eligible Employees) Option 1 Option 2 Option 3 Option 4 Available Without Medical Plan (Dental HMO Rider DMO Freedom of Choice PPO Max Monthly selection between the Standalone) to Groups DMO and PPO Max with 10 - 50 Eligible Employees MEMBER BENEFITS Basic Dental DMO Plan DMO Plan PPO Max Plan PPO Max Plan Rider to HMO- 100/80/50 100/90/60 100/70/40 100/80/50 based Medical Office Visit Copay $2 $5 $5 None None Dental Fund N/A N/A N/A N/A N/A Annual Deductible per Member None None None $50; 3X $50; 3X (does not apply to Diagnostic & Family Maximum Family Maximum Preventive Services) Annual Maximum Benefit None None None $1,000 $1,500 DIAGNOSTIC SERVICES Oral Exams Periodic oral exam 100% 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% 100% X-rays Bitewing — single film 100% 100% 100% 100% 100% Complete series 100% 100% 100% 100% 100% PREVENTIVE SERVICES Adult cleaning 100% 100% 100% 100% 100% Child cleaning 100% 100% 100% 100% 100% Sealants — per tooth Discounted Fee 100% 100% 100% 100% Fluoride application — with cleaning 100% 100% 100% 100% 100% Space maintainers Discounted Fee 100% 100% 100% 100% BASIC SERVICES Amalgam filling — 2 surfaces 100% 80% 90% 70% 80% Resin filling — 2 surfaces anterior Discounted Fee 80% 90% 70% 80% Oral Surgery Extraction – exposed root or erupted tooth Discounted Fee 80% 90% 70% 80% Extraction of impacted tooth — Discounted Fee 80% 90% 70% 80% soft tissue MAJOR SERVICES* Complete upper denture Discounted Fee 50% 60% 40% 50% Partial upper denture (resin base) Discounted Fee 50% 60% 40% 50% Crown — Porcelain with noble metal Discounted Fee 50% 60% 40% 50% Pontic — Porcelain with noble metal Discounted Fee 50% 60% 40% 50% Inlay — Metallic (3 or more surfaces) Discounted Fee 50% 60% 40% 50% Oral Surgery Removal of impacted tooth — Discounted Fee 50% 60% 40% 50% partially bony Endodontic Services Bicuspid root canal therapy Discounted Fee 80% 90% 40% 50% Molar root canal therapy Discounted Fee 50% 60% 40% 50% Periodontic Services Scaling & root planing — per quadrant Discounted Fee 80% 90% 40% 50% Osseous surgery — per quadrant Discounted Fee 50% 60% 40% 50% Orthodontic Services* Discounted Fee $2300 copay $2300 copay Not covered Not covered Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply Does not apply Does not apply Note: For New Jersey groups with 25 or more eligible employees, the DMO in Plan Option 2 cannot be sold on a standalone basis to a customer with primary business location in New Jersey. It must be part of a Dual Option sale packaged with either one of the PPO plans in Plan Options 4 - 6. The DentalFund in Plan Option 7 can be used to pay for any non-covered service. Any unused portion of the Fund will roll over to the next calendar year. *Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the Basic Dental Rider in Plan Option 1; DMO in Plan Options 2 & 3 or the DentalFund in Plan Option 7. Access to negotiated discounts; On the PPO plans in Plan Options 3-7, members are eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. The DMO in Plan Option 2 can be offered with any of the PPO plans in Plan Options 4 - 6 in a Dual Option package. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Plan Options 2 & 3 and the PPO in Plan Option 5 and are not subject to the coverage waiting period. Plan Options 3, 4 & 7; PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan’s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page 16. 9
NEW JERSEY AETNA SMALL GROUP DENTAL PLANS DENTAL PLAN OPTIONS Available With an Aetna Medical Plan to Groups with 2 - 50 Eligible Option 5 Option 6 Option 7 Employees Available Without Medical Active PPO High-Option Plan Passive Consumer Plan (Dental Standalone) to Groups PPO 1500 Directed with 10 - 50 Eligible Employees MEMBER BENEFITS Preferred Plan Non-Preferred PPO 1500 Plan DentalFund/ 100/80/50 Plan 80/60/40 100/80/50 PPO Max 100/0/0 Office Visit Copay None None None None Dental Fund N/A N/A N/A $50 Single; $100 Family Annual Deductible per Member $50; 3X Family $50; 3X Family $50; 3X Family None (does not apply to Diagnostic & Maximum Maximum Maximum Preventive Services) Annual Maximum Benefit $1,500 $1,000 $1,500 None DIAGNOSTIC SERVICES Oral Exams Periodic oral exam 100% 80% 100% 100% Comprehensive oral exam 100% 80% 100% 100% Problem-focused oral exam 100% 80% 100% 100% X-rays Bitewing — single film 100% 80% 100% 100% Complete series 100% 80% 100% 100% PREVENTIVE SERVICES Adult cleaning 100% 80% 100% 100% Child cleaning 100% 80% 100% 100% Sealants — per tooth 100% 80% 100% 100% Fluoride application — with cleaning 100% 80% 100% 100% Space maintainers 100% 80% 100% 100% BASIC SERVICES Amalgam filling — 2 surfaces 80% 60% 80% Discounted Fee Resin filling — 2 surfaces anterior 80% 60% 80% Discounted Fee Oral Surgery Extraction – exposed root or erupted tooth 80% 60% 80% Discounted Fee Extraction of impacted tooth — 80% 60% 80% Discounted Fee soft tissue MAJOR SERVICES* Complete upper denture 50% 40% 50% Discounted Fee Partial upper denture (resin base) 50% 40% 50% Discounted Fee Crown — Porcelain with noble metal 50% 40% 50% Discounted Fee Pontic — Porcelain with noble metal 50% 40% 50% Discounted Fee Inlay — Metallic (3 or more surfaces) 50% 40% 50% Discounted Fee Oral Surgery Removal of impacted tooth — 50% 40% 50% Discounted Fee partially bony Endodontic Services Bicuspid root canal therapy 80% 60% 50% Discounted Fee Molar root canal therapy 50% 40% 50% Discounted Fee Periodontic Services Scaling & root planing — per quadrant 80% 60% 50% Discounted Fee Osseous surgery — per quadrant 50% 40% 50% Discounted Fee Orthodontic Services* 50% 40% 50% Discounted Fee Orthodontic Lifetime Maximum $1,000 $1,000 $1,000 Does not apply Note: For New Jersey groups with 25 or more eligible employees, the DMO in Plan Option 2 cannot be sold on a standalone basis to a customer with primary business location in New Jersey. It must be part of a Dual Option sale packaged with either one of the PPO plans in Plan Options 4 - 6. The DentalFund in Plan Option 7 can be used to pay for any non-covered service. Any unused portion of the Fund will roll over to the next calendar year. *Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Does not apply to the Basic Dental Rider in Plan Option 1; DMO in Plan Options 2 & 3 or the DentalFund in Plan Option 7. Access to negotiated discounts; On the PPO plans in Plan Options 3-7, members are eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. The DMO in Plan Option 2 can be offered with any of the PPO plans in Plan Options 4 - 6 in a Dual Option package. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services on the DMO in Plan Options 2 & 3 and the PPO in Plan Option 5 and are not subject to the coverage waiting period. Plan Options 3, 4 & 7; PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan’s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page 16. 10
NEW JERSEY AETNA SMALL GROUP DENTAL PLANS OUT-OF-STATE/SITUS PPO PLAN OPTIONS Available With an Aetna Medical Plan (2 – 50 Eligible Employees) Low Option Low Option Medium Option Medium Option Available Without Medical Plan No Ortho* Ortho* No Ortho* Ortho* (Dental Standalone) to Groups with 10 - 50 Eligible Employees MEMBER BENEFITS PPO Max Plan PPO Max Plan PPO Max Plan PPO Max Plan 100/80/50 100/80/50 100/80/50 100/80/50 Office Visit Copay N/A N/A N/A N/A Annual Deductible per Member $50; 3X Family $50; 3X Family $50; 3X Family $50; 3X Family (does not apply to Diagnostic & Maximum Maximum Maximum Maximum Preventive Services) Annual Maximum Benefit $1,000 $1,000 $1,500 $1,500 DIAGNOSTIC SERVICES Oral Exams Periodic oral exam 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% X-rays Bitewing — single film 100% 100% 100% 100% Complete series 100% 100% 100% 100% PREVENTIVE SERVICES Adult cleaning 100% 100% 100% 100% Child cleaning 100% 100% 100% 100% Sealants — per tooth 100% 100% 100% 100% Fluoride application — with cleaning 100% 100% 100% 100% Space maintainers 100% 100% 100% 100% BASIC SERVICES Amalgam filling — 2 surfaces 80% 80% 80% 80% Resin filling — 2 surfaces anterior 80% 80% 80% 80% Oral Surgery Extraction – exposed root or erupted tooth 80% 80% 80% 80% Extraction of impacted tooth — 80% 80% 80% 80% soft tissue MAJOR SERVICES** Complete upper denture 50% 50% 50% 50% Partial upper denture (resin base) 50% 50% 50% 50% Crown — Porcelain with noble metal 50% 50% 50% 50% Pontic — Porcelain with noble metal 50% 50% 50% 50% Inlay — Metallic (3 or more surfaces) 50% 50% 50% 50% Oral Surgery Removal of impacted tooth — 50% 50% 50% 50% partially bony Endodontic Services Bicuspid root canal therapy 50% 50% 50% 50% Molar root canal therapy 50% 50% 50% 50% Periodontic Services Scaling & root planing — per quadrant 50% 50% 50% 50% Osseous surgery — per quadrant 50% 50% 50% 50% Orthodontic Services** Not covered 50% Not covered 50% Orthodontic Lifetime Maximum Does not apply $1,000 Does not apply $1,000 *Employees inside of the situs rating area are: Connecticut, Delaware, Maryland, New Jersey, New York, Pennsylvania, Virginia and Washington, D.C. where Aetna has an HMO and/or PPO network. Out-of-State/Situs PPO plans are not available in some states. The Out-of-State/Situs Traditional plan is offered in Arkansas, Alaska, Hawaii, Idaho, Maine, Montana, North Dakota, New Hampshire, New Mexico, South Dakota, Vermont and Wyoming. **Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Access to negotiated discounts; On all PPO Max plans, members are eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan’s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page 16. 11
Small Business decision makers can choose from a selection of Aetna Life and Disability affordable life and disability benefit solutions to meet your employees’ needs. We also provide extra value through a variety of services for your employees. The streamlined Life and Disability Life Insurance ■ Premium Waiver Provision — package includes a range of flat Employee coverage may stay in effect dollar insurance options bundled Life insurance is an inexpensive way to together in one monthly per up to age 65 without premium pay- provide a death benefit for employees that employee rate — resulting in a ments if an employee is permanently will help them establish essential financial simplified quotation process. These and totally disabled while insured products are easy to understand, protection for themselves and their fami- because of an illness or injury prior to and offer affordable benefits lies. Aetna offers a wide range of flat dol- age 60. together with valuable services lar insurance options for basic employee at no additional cost. Plan sponsors term life insurance with rates guaranteed ■ Guaranteed Issue — For Basic Term will also benefit from streamlined not to increase for a period of two years Life, coverage is individually “guaran- plan installation, administration from your policy’s effective date. Aetna teed issue” up to $20,000 for groups and claims processing. Or, if a Life solution is all you’re looking for, Small Group life insurance plans auto- with 2-9 eligible employees, $75,000 you may also just simply choose matically come with many value-added for groups of 10-25 eligible employees, from our portfolio of Group Basic features, including: and $100,000 for groups of 26-50 Term Life plans. eligible employees. For Packaged ■ AD&D Ultra® — Automatically Life insurance customers have Life/Disability, the guaranteed issue included in all employee term life plans access to free investment planning amounts for groups of 2-50 eligible is an Accidental Death and Personal services through an arrangement employees are $10,000 for the Low Loss benefit called AD&D Ultra. with Chase Investment Services Option and $20,000 for the Medium Corp. (CISC)*, an affiliate of J.P. AD&D Ultra provides a benefit up to Option. For the High Option, the Morgan Chase & Co. The program the amount of group life insurance for guaranteed issue amount is $20,000 is available to all beneficiaries certain accidental losses. Aetna calls regardless of their benefit payout for groups of 2-9 eligible employees it AD&D Ultra because it includes and provides investment planning and $50,000 for groups of 10-50 eligi- seven benefits that set the standard from a CISC Financial Consultant ble employees. for accidental loss protection. These through a toll-free number. benefits include: ■ Optional Dependent Life Insurance Aetna’s Legal Reference Program* — Ability to add optional additional offers free information, as well as > Passenger Restraint & Airbag coverage for eligible spouses and discounted legal services to plan > Education Benefit for Dependent children for employers with 10 or members through Advisory Child and/or Spouse Communications Systems, Inc. more employees. This benefit enables > Child Care Benefit employees to protect their spouses and * For the Aetna Beneficiary Solutions Program, secu- > Repatriation of Remains Benefit dependent children in flat amounts rities and investment advisory services are inde- at employee expense. pendently offered through Chase Investment Services Corp. (CISC). A member of NASD/SIPC > Coma Benefit and a subsidiary of J.P. Morgan Chase Bank, CISC ■ Aetna Beneficiary SolutionsTM is a full-service broker-dealer and Registered > Total Disability Benefit Investment Advisor. Aetna does not warrant or Program* — A program that provides guarantee and makes no representations as to the quality of services offered by CISC. The Legal > 365-Day Covered Loss Period an interest-bearing account, cus- Reference Program is independently offered and administered by Advisory Communications ■ Accelerated Death Benefits — Also tomized investment programs with Systems, Inc. (ACS). Aetna does not participate in attorney selection or review, and does not monitor called the “living benefit,” provides confidential, free financial counseling ACS services, content or network. Aetna does not through Chase Investment Services provide legal services and makes no representa- payment to terminally ill employees or tions or warranties as to the quality of the services spouses. The payment can be up to Corp., as well as Aetna’s Legal of ACS or of any attorney in the ACS network. 50% of the life insurance benefit Reference Program for all beneficiaries. (minimum of $5,000). 12
Disability ■ We align clinical and claim management ■ Simplified quotation process — no extra experience with the nature and complexity information is needed and rates are set. Disability insurance provides a partial of each claim to provide the right touch replacement of lost income for the ■ Streamlined plan installation, at the right time™ for you and your ill or employee, and helps reduce employer administration and claims processing. injured employees. costs compared to the cost of carrying ■ Specially designed Disability product, disabled employees on the payroll while Packaged Life and Disability which is a combination of Short and also paying overtime to other employees Long Term Disability benefits that — or hiring replacements. Aetna offers a streamlined product that at a crucial time — helps employees combines basic life, AD&D, dependent Through Aetna Disability Services®, plan bridge from most employer-sponsored life, and disability insurance coverages in administration is easy and dependable: salary continuation to Social Security. one convenient package. To make it easy to ■ Fast, accurate claim payments from our choose, we’ve designed three alternatives ■ The Disability portion of this product dedicated disability benefit system that that provide different levels of life and dis- offers coverage for occupational and automates benefit calculations, claim ability coverage for a set price — Low, non-occupational injuries and illnesses. histories, and audit and security features. Medium and High plans. These plans offer a range of flat dollar insurance options NOTE: For a summary list of AD&D Ultra ■ Designated claim analysts who serve as bundled together in one monthly per and Disability Limitations and Exclusions, refer the employee’s single point of contact to employee rate. to page 16. our team of claim and clinical profes- sionals. Nurse case managers and voca- There are several advantages to choosing tional rehabilitation specialists are avail- these options: able to work with employees facing ■ One-stop shopping complex clinical and functional chal- lenges to help achieve a positive out- ■ Plans are designed to meet the business come for the employee and cost-effec- needs of small business owners. tive claim management for you. 13
LIFE AND DISABILITY BENEFITS A E T N A S M A L L G R O U P PA C K A G E D L I F E & D I S A B I L I T Y P L A N O P T I O N S Packaged Life Low Medium High & Disability Benefits Option Option Option BASIC LIFE PLAN DESIGN Benefit Flat $10,000 Flat $20,000 Flat $50,000 Guaranteed Issue 2 – 9 Lives $10,000 $20,000 $20,000 10 – 50 Lives $10,000 $20,000 $50,000 Reduction Schedule Employee’s Original Life Employee’s Original Life Employee’s Original Life Amount Reduces to 65% at Amount Reduces to 65% at Amount Reduces to 65% at age 65; 40% at age 70; age 65; 40% at age 70; age 65; 40% at age 70; 25% at age 75 25% at age 75 25% at age 75 Premium Waiver Provision Premium Waiver 60 Premium Waiver 60 Premium Waiver 60 Accelerated Death Benefit Up to 50% of Life Amount Up to 50% of Life Amount Up to 50% of Life Amount Dependent Life Spouse $5,000; Child $2,000 Spouse $5,000; Child $2,000 Spouse $5,000; Child $2,000 AD&D Ultra® Matches Basic Life Benefit Matches Basic Life Benefit Matches Basic Life Benefit Additional Features Passenger Restraint & Airbag, Education (for dependent child and/or spouse), Child Care, Repatriation, Coma, Total Disability, 365-Day Covered Covered Loss DISABILITY PLAN DESIGN Monthly Benefit Flat $500; Flat $1,000; Only offset Workers’ Flat $1,000; Only offset Workers’ No offsets Compensation, any state Compensation, any state disability plan, and primary & disability plan, and primary & family Social Security benefits family Social Security benefits Benefit if applicable Benefit if applicable Elimination Period 30 days 30 days 30 days Definition of Disability Own occupation Own occupation First 24 months of benefits: Own 20% Earnings Loss 20% Earnings Loss Occupation Earnings Loss of 20% or (80% Earnings Test) (80% Earnings Test) more; Any reasonable occupation thereafter: 40% earnings loss. Benefit Duration 24 months of benefits 24 months of benefits 60 months of benefits Pre-Existing Condition Limitation 3/12 3/12 3/12 Types of Disability Occupational & Non-Occupational Occupational & Non-Occupational Occupational & Non-Occupational Mental Health/Substance Abuse 24 months of benefits 24 months of benefits 24 months of benefits Rates* (per employee per month) $8 $15 $27 *The above rates are valid for effective dates up to December 31, 2005 and are guaranteed for an assumed 12-month first-year policy period. 14
TERM LIFE BENEFITS AETNA SMALL GROUP BASIC EMPLOYEE TERM LIFE PLAN OPTIONS Term Life Benefits are also available separately from the packaged product. Term Life Benefits 2 – 9 Employees 10 – 50 Employees Basic Life Schedule Flat $10,000, $15,000, $20,000, $50,000 Flat $10,000, $15,000, $20,000, $50,000, $75,000, $100,000, $125,000 Class Schedules Not Available Up to 3 classes (with a minimum requirement of 3 employees in each class)— the benefit amount of the highest class cannot be more than 5 times the benefit amount of the lowest class Premium Waiver Provision Premium Waiver 60 Premium Waiver 60 Age Reduction Schedule Original Life Amount Reduces to 65% at Original Life Amount Reduces to 65% at age 65, 40% at age 70, 25% at age 75 age 65, 40% at age 70, 25% at age 75 Accelerated Death Benefit Up to 50% of Life Amount Up to 50% of Life Amount Guaranteed Issue $20,000 10-25 - $75,000 26-50 - $100,000 Participation Requirements 100% 100% on noncontributory plans; 75% on contributory plans Contribution Requirements 100% Employer Contribution Minimum 50% Employer Contribution AD&D ULTRA® AD&D Schedule Automatically Included; Same as Life plan Automatically Included; Same as Life plan Additional Features Passenger Restraint & Airbag, Education (for Passenger Restraint & Airbag, Education (for dependent child and/or spouse), Child Care, dependent child and/or spouse), Child Care, Repatriation, Coma, Total Disability, 365-Day Repatriation, Coma, Total Disability, 365-Day Covered Loss Covered Loss OPTIONAL DEPENDENT TERM LIFE Spouse Amount Not Available $5,000 Child Amount Not Available $2,000 15
Limitations and Exclusions Dental Limitations and AD&D Ultra Limitations Disability Limitations and Exclusions and Exclusions Exclusions Listed below are some of the charges and This coverage is only for losses caused No benefits are payable if the disability: services for which these dental plans do by accidents. No benefits are payable for ■ Is due to intentionally self-inflicted not provide coverage. For a complete list a loss caused or contributed to by: injury (while sane or insane). of exclusions and limitations, refer to ■ A bodily or mental infirmity. ■ Results from your committing, or plan documents. ■ A disease, ptomaine or bacterial infection.* attempting to commit, a felony. ■ Dental services or supplies that are ■ Medical or surgical treatment.* ■ Is due to insurrection, rebellion or primarily used to alter, improve or ■ Suicide or attempted suicide taking part in a riot or civil commotion. enhance appearance. (while sane or insane). ■ Is due to war or any act of war ■ Experimental services, supplies or ■ An intentionally self-inflicted injury. (declared or not declared) procedures. ■ A war or any act of war (declared ■ Results from an automobile accident ■ Treatment of any jaw joint disorder, such or not declared). caused by you while you are intoxicated. as temporomandibular joint disorder. (“Intoxicated” means: the blood ■ Replacement of lost, missing or stolen ■ Voluntary inhalation of poisonous gases. alcohol level of the driver of the auto- appliances and certain damaged appliances. ■ Commission of or attempt to commit a mobile meets or exceeds the level at ■ Those services that Aetna defines as not felony provided that the covered which intoxication would be pre- necessary for the diagnosis, care person is convicted of the felony. sumed under the law of the state or treatment of a condition involved. ■ A covered person’s intoxication or being where the accident occurred.) under the influence of any narcotics On any day during a period of Specific service limitations unless administered or consumed on the disability that a person is confined ■ DMO Plans: Oral exams (4 per year) advice of a physician. in a penal or correctional institution ■ PPO Plans: Oral exams (2 routine ■ Intended or accidental contact with for conviction of a criminal or other and 2 problem-focused per year) nuclear or atomic energy by explosion public offense, the person will not be ■ All Plans: and/or release. deemed to be disabled and no benefits > Bitewing X-rays (1 set per year) ■ Air or space travel. This does not apply will be payable. > Complete series X-rays if a person is a passenger, with no duties No benefit is payable for any disability (1 set every 3 years) at all, on an aircraft being used only to that occurs during the first 12 months > Cleanings (2 per year) carry passengers (with of coverage and is due to a pre-existing > Fluoride (1 per year; children or without cargo). condition for which the member was under 16) *These do not apply if the loss is diagnosed, treated or received services, > Sealants (1 treatment per tooth, caused by: treatment, drugs or medicines three (3) every 3 years on permanent molars; months prior to coverage effective date. ■ An infection that results directly from children under 16) the injury, or surgery needed because > Scaling & root planing of the injury. The injury must not be (4 quadrants every 2 years) one that is excluded by the terms of > Osseous surgery (1 per quadrant the contract. every 3 years) ■ All other limitations and exclusions in your plan documents. 16
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna companies that offer, underwrite or administer benefits coverage include Aetna Health Inc., Aetna Life Insurance Company and/or Aetna Dental Inc. For the Aetna Golden Choice Plan, Corporate Health Insurance Company also offers, underwrites or administers benefits. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna arranges for the provision of healthcare/dental services. However, Aetna itself is not a provider of healthcare/dental servic- es and therefore, cannot guarantee any results or outcomes. Consult the plan documents (Schedule of Benefits, Certificate of Coverage, Evidence of Coverage, Group Agreement, Group Insurance Certificate, Booklet, Booklet- certificate, Group Policy) to determine governing contractual provisions, including procedures, exclusions and lim- itations relating to the plan. The availability of a plan or program may vary by geographic service area and by plan design. With the exception of Aetna Rx Home Delivery® service, participating providers and vendors are independ- ent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. Notice of the change shall be provided in accordance with applicable state law. Certain primary care providers are affiliated with integrated delivery systems or other provider groups (such as independent practice associations and physician-hospital organizations), and members who select these providers will generally be referred to specialists and hospitals within those systems or groups. However, if a system or group does not include a provider qualified to meet member’s medical needs, member may request to have services provided by non-system or non-group providers. Member’s request will be reviewed and will require prior authorization from the system or group and/or Aetna to be a covered benefit. Information supplied by Aetna InteliHealth® is for informational purposes only, is not medical advice and is not intended to be a substitute for proper medical care provided by a physician. Informed Health® Line nurses cannot diagnose, prescribe or give medical advice. Specific questions should be addressed to your doctor. Alternative health care programs, Vision One® and the fitness program are rate-access programs and may be in addition to any plan benefits. Program providers are solely responsible for the products and services provided thereunder. Aetna does not endorse any vendor, product or service associated with these programs. Discounts offered hereun- der are not insurance. Some benefits are subject to limitations or visit maximums. Members or Providers may be required to precertify, or obtain prior approval of coverage for certain services such as non-emergency inpatient hospital care. If your plan covers outpatient prescription drugs, your plan may include a drug formulary (preferred drug list). A formulary is a list of prescription drugs generally covered under your prescription drug benefits plan on a preferred basis subject to applicable limitations and conditions. Your pharmacy benefit is generally not limited to the drugs listed on the formulary. The medications listed on the formulary are subject to change in accordance with applicable state law. For information regarding how medications are reviewed and selected for the formulary, formulary information, and information about other pharmacy programs such as precertification and step-therapy, please refer to Aetna’s website at www.aetna.com, or the Aetna Medication Formulary Guide. Many drugs, including many of those listed on the formulary, are subject to rebate arrangements between Aetna and the manufacturer of the drugs. Rebates received by Aetna from drug manufacturers are not reflected in the cost paid by a member for a prescription drug. In addition, in circumstances where your prescription plan utilizes copayments or coinsurance calculated on a percentage basis or a deductible, use of formulary drugs may not necessarily result in lower costs for the member. Members should consult with their treating physicians regarding questions about specific medications. Refer to your plan documents or contact Member Services for information regarding the terms and limitations of coverage. Closed formularies and step therapy do not apply to New Jersey plan options. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a subsidiary of Aetna Inc., that is a licensed pharmacy providing mail-order pharmacy services. Aetna’s negotiated charge with Aetna Rx Home Delivery may be higher than Aetna Rx Home Delivery’s cost of purchasing drugs and providing mail-order pharmacy services. Aetna does not credential or otherwise make any representations as to the quality or appropriateness of long-term care providers offering discounts to Aetna members. While this material is believed to be accurate as of the print date, it is subject to change.
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