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14.02.988.1-LA B (10/12)

Louisiana Small Business Plan Options

Plans effective September 1, 2012 For businesses with 2-50 eligible employees

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LA PPO 1500 80/60–12 LA PPO 2000 100%–12

Member Benefits In network Out of network* In network Out of network*

Coinsurance 20% 40% 0% 30%

Calendar-Year Deductible1 Individual Family

$1,500 3 member max

$3,000 3 member max

$2,000 3 member max

$4,000 3 member max

Calendar-Year Out-Of-Pocket Maximum2 Individual Family

$3,500 3 member max

$7,000 3 member max

N/A N/A

$6,000 $12,000

Lifetime Maximum Benefit Unlimited Unlimited

Office Visits (Primary physician/Non-specialist) $30 deductible waived 40% $30 deductible waived 30%

Office Visits (Specialist) $50 deductible waived 40% $50 deductible waived 30%

Diagnostic Procedures

Outpatient Lab $30 deductible waived 40% $30 deductible waived 30%

Outpatient X-Rays/Testing (Facility) $30 deductible waived 40% $30 deductible waived 30%

Outpatient Complex Imaging 20% 40% 0% 30%

Inpatient Hospital Services 20% 40% 0% 30%

Outpatient Surgery 20% 40% 0% 30%

Emergency Room (Copay waived if admitted) 20% after $150, deductible waived

Paid as in network $200 deductible waived Paid as in network

Urgent Care $75 deductible waived 40% $100 deductible waived 30%

Skilled Nursing Facility (60 days per calendar year limit) 20% 40% 0% 30%

Hospice Care Inpatient Outpatient

20% 20%

40% 40%

0% 0%

30% 30%

Home Health Care (60 visits per calendar year limit) 20% 40% 0% 30%

Durable Medical Equipment ($2,500 per member, per calendar year maximum)

20% 40% 0% 30%

Preventive Care (includes well-child exams, Adult physicals, routine Gyn, routine mammograms)

$0 deductible waived 40% $0 deductible waived 30%

Prescription Drugs

Pharmacy (Retail, 30-day supply; includes diabetic supplies)

$15/$40/$60/30% Retail copay + 30% $15/$40/$60/30% Retail copay + 30%

2

See page 5 for footnotes.Health insurance plans are underwritten by Aetna Life Insurance Company (Aetna).

LA PPO 2500 80/50–12 LA PPO 3000 100%–12


Coinsurance 20% 50% 0% 30%


$2,500 3 member max

$5,000 3 member max

$3,000 3 member max

$5,000 3 member max


$5,000 3 member max

$10,000 3 member max

N/A N/A

$7,000 3 member max

Lifetime Maximum Benefit Unlimited Unlimited

Office Visits (Primary physician/Non-specialist) $30 deductible waived 50% $30 deductible waived 30%

Office Visits (Specialist) $60 deductible waived 50% $50 deductible waived 30%


Outpatient Lab $30 deductible waived 50% $30 deductible waived 30%

Outpatient X-Rays/Testing (Facility) $30 deductible waived 50% $30 deductible waived 30%

Outpatient Complex Imaging 20% 50% 0% 30%

Inpatient Hospital Services 20% 50% 0% 30%

Outpatient Surgery 20% 50% 0% 30%


Paid as in network $250 deductible waived Paid as in network

Urgent Care $100 deductible waived 50% $100 deductible waived 30%

Skilled Nursing Facility (60 days per calendar year limit) 20% 50% 0% 30%


20% 20%

50% 50%

0% 0%

30% 30%

Home Health Care (60 visits per calendar year limit) 20% 50% 0% 30%


20% 50% 0% 30%


$0 deductible waived 50% $0 deductible waived 30%

Prescription Drugs


$15/$40/$60/30% Retail copay + 30% $15/$40/$60/30% Retail copay + 30%


3

4

LA PPO 5000 70/50–12 LA HSA 3000–12LA Traditional Choice–12


Coinsurance 30% 50% 10% 30% 20%


$5,000 3 member max

$7,500 3 member max

$3,000 $6,000+

$6,000 $12,000

$1,500 $3,000+++


$7,500 3 member max

$10,000 3 member max

$5,950 $11,900++

$12,000 $24,000

$6,000 $12,000++++

Lifetime Maximum Benefit Unlimited Unlimited Unlimited

Office Visits (Primary physician/Non-specialist) $30 deductible waived

50% 10% 30% 20%

Office Visits (Specialist) $60 deductible waived

50% 10% 30% 20%


Outpatient Lab $30 deductible waived

50% 10% 30% 20%

Outpatient X-Rays/Testing (Facility) $30 deductible waived

50% 10% 30% 20%

Outpatient Complex Imaging 30% 50% 10% 30% 20%

Inpatient Hospital Services 30% 50% 10% 30% 20%

Outpatient Surgery 30% 50% 10% 30% 20%


Paid as in network 10% 30% 20%

Urgent Care $100 deductible waived

50% 10% 30% 20%

Skilled Nursing Facility (60 days per calendar year limit) 30% 50% 10% 30% 20%


30% 30%

50% 50%

10% 10%

30% 30%

20% 20%

Home Health Care (60 visits per calendar year limit) 30% 50% 10% 30% 20%


30% 50% 10% 30% 20%


$0 deductible waived

50% $0 deductible waived

30% 0% deductible waived

Prescription Drugs


$15/$40/$60/30% Retail copay + 30% $15/$40/$60 after integrated medical deductible

Retail copay + 30% after integrated medical deductible

$15/$40/$60


5

Please read the notes below. They contain important information about these health plans.

*We cover the cost of services based on whether doctors are “in network” or “out of network.” We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this “out-of-network” care. You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out-of-network, your Aetna health plan may pay some of that doctor’s bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the “recognized” or “allowed” amount. When you choose out-of-network care, Aetna “recognizes” an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your doctor sets his or her own rate to charge you. It may be higher — sometimes much higher — than what your Aetna plan “recognizes.” Your doctor may bill you for the dollar amount that Aetna doesn’t “recognize.” You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the “recognized charge” counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit www.aetna.com. Type “how Aetna pays” in the search box. You can avoid these extra costs by getting your care from Aetna’s broad network of health care providers. Go to www.aetna.com and click on “Find a Doctor” on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site.

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

1All services subject to deductible unless otherwise noted. In-network and out-of-network expenses accumulate separately and do not cross apply. Three members must individually meet their deductible before the family deductible is considered to have been met. No one family member may contribute more than the individual deductible amount to the family deductible. Deductible does not apply to the out-of-pocket maximum.

2Out-of-pocket maximum excludes deductible, copayments and pharmacy expenses. All other covered expenses accumulate separately toward the in-network and out-of-network out-of-pocket maximums and do not cross apply. Three members must individually meet their out-of-pocket maximum before the family out-of-pocket maximum is considered to have been met.

+HSA plan - All services including pharmacy expenses are subject to deductible except office visits for routine preventive services. Once the family deductible is met, all family members will be considered as having met their deductible for the remainder of the calendar year. No one family member may contribute more than the individual deductible amount to the family deductible.

++HSA plan - Out-of-pocket maximum includes deductible, member’s share of coinsurance, copay (if applicable), and pharmacy expenses. Once the family out-of-pocket maximum is met, all family members will be considered as having met their out-of-pocket maximum for the remainder of the calendar year. No one family member may contribute more than the individual out-of-pocket maximum to the family out-of-pocket maximum.

+++Traditional Choice - All services subject to deductible unless otherwise noted. Once the family deductible is met, all family members will be considered as having met their deductible for the remainder of the calendar year. No one family member may contribute more than the individual deductible amount to the family deductible.

++++Traditional Choice - Out-of-pocket maximum excludes deductible, copay (if applicable) and pharmacy expenses. Once the family out-of-pocket maximum is met, all family members will be considered as having met their out-of-pocket maximum for the remainder of the calendar year. No one family member may contribute more than the individual out-of-pocket maximum to the family out-of-pocket maximum.

This is a partial description of benefits available; for more information refer to the specific plan design summary. All services are subject to deductible unless otherwise noted. The dollar amount copayments indicate what the member is required to pay and the percentage amounts indicate what Aetna is required to pay. Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain approval for certain services such as non-emergency hospital care.

Footnotes

Limitations & exclusions

Medical limitations and exclusions

This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer.

• All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents

•Cosmetic surgery, including breast reduction

• Custodial care

• Dental care and dental X-rays

•Donor egg retrieval

•Experimental and investigational procedures, except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial

•Home births

•Immunizations for travel or work except where medically necessary or indicated

•Implantable drugs and certain injectable drugs including injectable infertility drugs

• Infertility services, including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents

•Long-term rehabilitation therapy

• Non-medically necessary services or supplies

•Orthotics except diabetic orthotics

•Radial keratotomy or related procedures

•Reversal of sterilization

•Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies or counseling or prescription drugs

•Special duty nursing

•Therapy or rehabilitation other than those listed as covered

•Treatment of behavioral disorders

•Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including morbid obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions

Pre-Existing Conditions Exclusion Provision

For members age 19 or over this plan imposes a pre-existing conditions exclusion, which may be waived in some circumstances (that is, creditable coverage) and may not be applicable to you. A pre-existing condition exclusion means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis or treatment was recommended or received or for which the individual took prescribed drugs within 90 days.

Generally, this period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the 90-day period ends on the day before the waiting period begins. The exclusion period, if applicable, may last up to 365 days from your first day of coverage, or, if you were in a waiting period, from the first day of your waiting period.

If you had prior creditable coverage within 90 days immediately before the date you enrolled under this plan, then the pre-existing conditions exclusion in your plan, if any, will be waived.

If you had no prior creditable coverage within the 90 days prior to your enrollment date (either because you had no prior coverage or because there was more than a 90-day gap from the date your prior coverage terminated to your enrollment date), we will apply your plan’s pre-existing conditions exclusion.

In order to reduce or possibly eliminate your exclusion period based on your creditable coverage, you should provide us a copy of any Certificates of Creditable Coverage you have. Please contact your Aetna Member Services representative at 1-888-80-AETNA (1-888-802-3862) if you need assistance in obtaining a Certificate of Creditable Coverage from your prior carrier or if you have any questions on the information noted above.

The pre-existing condition exclusion does not apply to pregnancy or to a child under the age of 19. Note: For late enrollees, coverage will be delayed until the plan’s next open enrollment; the pre-existing exclusion will be applied from the individual’s effective date of coverage.

6

Health Reform Disclosure and Caveat: You should also be aware that the Federal government released regulations related to grandfathering of health plans in existence on March 23, 2010. Changes in your benefits design as well as your contribution strategy may affect grandfathering. Your renewal offerings may not preserve grandfathering. This is an additional factor you may wish to consider as you review the plan design options in your renewal packet. Aetna reserves the right to modify its products, services, rates and fees, in response to legislation, regulation or requests of government authorities resulting in material changes to plan benefits and to recoup any material fees, costs, assessments, or taxes due to changes in the law even if no benefits or plan changes are mandated. This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits vary by location. Health insurance plans contain exclusions and limitations. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com.

www.aetna.com

©2012 Aetna Inc. 14.02.988.1-LA B (10/12)

louisiana small business plan options - aetna.com€¦ · louisiana small business plan options...

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