Questions and Answers

Transcripción

Aetna Voluntary Plans
Open enrollment
begins
September 1
and ends
September 30, 2011.
Questions
and Answers
Membership information you need to know
Just hired?
You have 90 days from
the date you are hired
to enroll.
How do I decide if this plan is right for me?
Please read the information in this enrollment kit, including your Benefits Summary, which
explains some of the benefits, limitations, features, and exclusions of this plan. Consider the
amount you will pay in premiums, as shown on the Enrollment/Change Request form, and
compare this plan to any other medical coverage options you may have. If you have any
questions or need additional information, please call us toll-free at 1-888-772-9682.
If you do not enroll
now, you cannot
enroll until the next
open enrollment,
unless you have a
qualifying life event.
How does a fixed indemnity plan work?
Fixed indemnity plans have no copays, deductibles, or coinsurance. A fixed indemnity plan
pays a fixed amount per service, with limits on the number and types of services. Once you
have used up your number of services, the plan will no longer pay for that kind of service.
Because the plan pays a fixed amount, you may owe the provider more than the plan pays. If
you choose a preferred (in network) provider, then you may pay less, because the provider
may accept payment for the negotiated in-network fee. Before you enroll in the plan, please
read the benefits chart in the previous pages carefully to understand what this plan will pay.
Who can participate?
All full-time General Cleaners and all other full-time employees who are not eligible for
another medical plan offered by WFF Facilty Service are eligible to participate after completing
90 days of service. If you are an eligible employee, you can also enroll your eligible
dependents (except for Short Term Disability). Your eligible dependents are your lawful spouse
and your children from birth until age 26, through any age if handicapped and unable to earn
a living, or until they can no longer be legally declared as dependents. Dependent age and
status requirements may vary by state.
When does coverage begin?
Coverage is effective on the first day of the month after you enroll and after you have
completed your 90-day waiting period.
When do limits reset?
Annual limits add up throughout the coverage year, then reset and begin
again on the anniversary date of your coverage year, October 1.
Will I get ID cards?
If you choose medical benefits, you will get plastic member identification
(ID) cards. Until you get your plastic IDs, please use the temporary member
ID at lower right. This ID is valid after you enroll and your benefits begins.
How do I file a claim?
Claim forms are available from www.aetna.com/docfind/custom/avp, by
calling SRC toll-free at 1-888-772-9682, or by writing to Strategic Resource
Company, Attn: Claims Department, P.O. Box 14079,
Lexington, KY 40512-4079.
Cut out your temporary member identification along the dotted line.
DOI
MEDICAL PPO
AETNA VOLUNTARY PLANS
BIN# 610502
EMPLOYEE NAME: _________________________________________________________________
AND COVERED DEPENDENTS
FOR MEMBER SERVICES CALL
1-888-772-9682
PAYOR NUMBER 57604 0039
AVFBP
12.03.359.1 CleanTechC (8/11)
RX
CLEAN-TECH COMPANY/WITT, FIALA, FLANNERY AND ASSOCIATES, INC.
DBA WFF FACILITY SERVICES
COMPANY NO.: 801920
www.aetna.com/docfind/custom/avp
HEALTH CARE PROVIDER: The person listed on the front of this card has
been enrolled under a fixed indemnity insurance plan sponsored by the
employer listed on the front of this card. Covered members are entitled
to benefits under the applicable plan, subject to exclusions and
limitations. This card does not guarantee coverage. For verification of
coverage, filing a claim or for questions other than the discount
programs, contact us at the number printed on the front of this card or
mail us at the address below.
INSURED: Network physicians, hospitals, and other health care providers
are independent contractors and are neither agents nor employees of Aetna
Life Insurance Company.
EMERGENCY URGENT CARE: Call your local emergency hotline (ex.911) or go
to the nearest emergency facility. For AETNA VISION DISCOUNTS call
1-800-793-8616. For LASIK call 1-800-422-6600. For CONTACTS DIRECT call
1-800-391-5367.
Strategic Resource Company
P.O. Box 14079
Lexington, KY 40512-4079
Notice to members concerning health care services: Your
share of the payment for health care services may be based on the
agreement between your health plan and your provider. Under
certain circumstances, this agreement may allow your provider to bill
you for amounts up to the provider’s regular billed charges.
More questions?
To get help in any language, call toll-free 1-888-772-9682
Monday through Friday, 8 a.m. to 8 p.m. Eastern Time.
¿Tiene más preguntas?
Si necesita ayuda en cualquier idioma, llame sin cargo al 1-888-772-9682
de lunes a viernes de 8 a.m. a 8 p.m., hora del Este.
Insurance Plans are underwritten by Aetna Life Insurance Company. Plans are administered by Strategic
Resource Company (SRC). Information is believed to be accurate as of the production date; however, it is subject to
change. For OK residents only, policy forms issued include GR-9/GR-9N, GR-29/GR-29N, GR96172, and GR96173.
AVFBP
12.03.359.1 CleanTechC (8/11)
Clean-Tech Company/Witt, Fiala, Flannery
and Associates, Inc. dba WFF Facility Services
801920
BENEFITS SUMMARY
Plan design and benefits provided by Aetna Life Insurance Company (Aetna)
and administered by Aetna or Strategic Resource Company (SRC).
Unless otherwise indicated, all benefits and limitations are per covered person.
Inside this Benefits Summary:
• Hospital and Medical Indemnity
• Hospital Indemnity
• Vision Care
• Short Term Disability (STD)
IMPORTANT INFORMATION ABOUT THE BENEFITS YOU ARE BEING OFFERED: Save this
statement! It may be important to you in the future. These benefits are not comprehensive health
care insurance and will not cover the cost of most hospital and other medical services. This
disclosure provides a very brief description of the important features of the benefits being considered. It
is not an insurance contract and only the actual policy provisions will control. The policy itself will include
in detail the rights and obligations of both the master policyholder and Aetna Life Insurance Company.
These benefits are designed to pay you fixed dollar amounts regardless of the amount that the provider
charges. Payments are not based on a percentage of the provider’s charge and are paid in addition to
any other health plan coverage you may have.
Aetna will pay benefits only for expenses incurred while these benefits are in force, and only for the medically necessary
treatment of injury or disease. The benefits displayed in this Benefits Summary reflect certain mandate(s) of the state in which
this policy was written. However, certain federal laws or other mandate(s) in the state you live and/or work could also affect
how these benefits pay.
Hospital and Medical Indemnity Benefits: Option 1
Most this plan will pay per coverage year for:
Outpatient doctors' office visits
Preventive visits
Outpatient diagnostic services
Emergency room
Ambulance
Outpatient surgery
Outpatient anesthesia
Treatment relating to accidents
Hospital admission
Inpatient hospital stays
Hospital room
or Intensive Care Unit
Inpatient surgery
Inpatient anesthesia
Inpatient doctors' visits
Prescription drugs
08/16/2011
5 visits at $55 per visit
1 visit at $75 per visit
3 days at $65 per day
3 trips at $50 per trip
2 surgeries at $150 per surgery
2 times at $75 each time
2 incidents at $100 per incident
2 admissions at $400 per admission
2 stays at $250 per day for 30 days
1 visit per day at $25 per visit for 30 days
12 prescriptions at $20 per prescription
Benefits Summary
Page 1
801920
Hospital and Medical Indemnity Benefits: Option 2
Most this plan will pay per coverage year for:
Preventive visits
Emergency room
Ambulance
Outpatient surgery
Hospital admission
Inpatient hospital stays
Hospital room
or Intensive Care Unit
Inpatient surgery
Prescription drugs
08/16/2011
1 visit at $100 per visit
4 days at $80 per day
3 trips at $100 per trip
2 incidents at $150 per incident
2 admissions at $600 per admission
1 visit per day at $25 per visit for 30 days
12 prescriptions at $25 per prescription
Benefits Summary
Page 2
801920
This policy does not meet Massachusetts Minimum Creditable Coverage standards.
Hospital and Medical Indemnity: Option 1
The charge from the provider could be lower if you use a preferred Aetna network provider (based on provider and
location). To locate a preferred provider, call toll-free 1-888-772-9682 or visit www.aetna.com/docfind/custom/avp.
Includes doctors' service in the office, home, emergency room and walk-in clinic.
(Also, includes treatment for accidents after 72 hours.)
Maximum number of visits per coverage year
(Includes routine care through age 6)
Plan pays per visit
5 visits
$55
Preventive visits
1 visit
Plan pays per visit
$75
Excludes lab in doctors' office which is considered part of the office visit charge.
3 days
$65
Maximum number of days per coverage year
Plan pays per day
Emergency room
Plan pays per visit
3 visits
$100
Ambulance
Maximum number of trips per coverage year
Plan pays per trip
3 trips
$50
Outpatient surgery
Maximum number of surgeries per coverage year
2 surgeries
Plan pays per surgery
$150
Maximum number of anesthesia inductions per coverage year
2 times
Plan pays per anesthesia induction
$75
08/16/2011
Benefits Summary
Page 3
801920
Within 72 hours includes: Hospital emergency room, urgent care center, clinic or doctors' office.
Maximum number of incidents per coverage year
2 incidents
$100
Plan pays per incident
Hospital admission
Maximum number of hospital admissions per coverage year
2 admissions
Plan pays per admission
$400
Inpatient hospital stay
(Includes maternity)
Maximum number of stays per coverage year
2 hospital stays
Maximum number of days per hospital stay
30 days
Plan pays per day in a private or semi-private room
$250
Plan pays per day in Intensive Care Unit (ICU)
$500
Inpatient surgery
2 surgeries
$150
2 times
$75
Maximum number of visits per day
1 visit
Plan pays per visit
$25
30 days
Prescription drug charges
Maximum number of prescriptions per coverage year
12 prescriptions
Plan pays per each prescription
$20
To use your prescription benefit:
A) Present your Aetna identification (ID) card to the pharmacist.
B) Participating pharmacies will apply a discount.
C) You pay the amount charged by the pharmacy.*
D) Submit a medical claim form to SRC for reimbursement.*
* If the pharmacy submits your claim(s) for you, then these steps do not apply.
Covers only medical prescriptions, except for dental prescriptions issued in connection with treatment resulting from a covered
accident.
To find a preferred pharmacy, call toll-free 1-888-772-9682 or visit www.aetna.com/docfind/custom/avp.
Medicare Part D Notice: This prescription drug benefit does not meet the criteria for Medicare Part D coverage; it does not
match up to the plan offered under Medicare Part D.
08/16/2011
Benefits Summary
Page 4
801920
Hospital and Medical Indemnity: Option 2
The charge from the provider could be lower if you use a preferred Aetna network provider (based on provider and
location). To locate a preferred provider, call toll-free 1-888-772-9682 or visit w ww.aetna.com/docfind/custom/avp.
Includes doctors' service in the office, home, emergency room and walk-in clinic.
(Also, includes treatment for accidents after 72 hours.)
(Includes routine care through age 6)
Plan pays per visit
7 visits
$65
Preventive visits
1 visit
Plan pays per visit
$100
Excludes lab in doctors' office which is considered part of the office visit charge.
4 days
$80
Plan pays per day
Emergency room
Plan pays per visit
3 visits
$200
Ambulance
3 trips
$100
Maximum number of trips per coverage year
Plan pays per trip
Outpatient surgery
2 surgeries
$250
2 times
$125
08/16/2011
Benefits Summary
Page 5
801920
Within 72 hours includes: Hospital emergency room, urgent care center, clinic or doctors' office.
Maximum number of incidents per coverage year
2 incidents
Plan pays per incident
$150
Hospital admission
Maximum number of hospital admissions per coverage year
2 admissions
Plan pays per admission
$600
Inpatient hospital stay
(Includes maternity)
Maximum number of stays per coverage year
2 hospital stays
Maximum number of days per hospital stay
30 days
Plan pays per day in a private or semi-private room
$400
Plan pays per day in Intensive Care Unit (ICU)
$800
Inpatient surgery
2 surgeries
$250
2 times
$125
Maximum number of visits per day
1 visit
Plan pays per visit
$25
30 days
Prescription drug charges
Maximum number of prescriptions per coverage year
12 prescriptions
Plan pays per each prescription
$25
To use your prescription benefit:
A) Present your Aetna identification (ID) card to the pharmacist.
B) Participating pharmacies will apply a discount.
C) You pay the amount charged by the pharmacy.*
D) Submit a medical claim form to SRC for reimbursement.*
* If the pharmacy submits your claim(s) for you, then these steps do not apply.
Covers only medical prescriptions, except for dental prescriptions issued in connection with treatment resulting from a covered
accident.
To find a preferred pharmacy, call toll-free 1-888-772-9682 or visit www.aetna.com/docfind/custom/avp.
Medicare Part D Notice: This prescription drug benefit does not meet the criteria for Medicare Part D coverage; it does not
match up to the plan offered under Medicare Part D.
08/16/2011
Benefits Summary
Page 6
801920
When you enroll in Hospital and Medical Indemnity benefits, you also receive:
Aetna VisionSM Discounts*
Aetna VisionSM Discounts uses the nationwide EyeMed Select Network of vision care providers to offer you and your family
glasses, contact lenses, nonprescription sunglasses, contact lens solutions and other eye care accessories at discounted
prices. Plus, you can receive discounts on eye exams and LASIK eye surgery. For exams and eyewear call 1-800-793-8616.
For contacts call 1-800-391-5367. For LASIK customer service call 1-800-422-6600. You can also locate a local provider by
visiting www.aetna.com/docfind/custom/avp. This discount arrangement may not be available to Illinois residents.
Prescription drug discount program*
The prescription drug discount program gives you and your family access to over 59,000 retail pharmacies nationwide
including major pharmacy chains and independent pharmacies (Aetna Network Pharmacy Database - 3/20/08). You can also
use our Aetna Rx Home Delivery® service; a fast, easy way to fill the prescriptions you take regularly. To locate a participating
pharmacy, call 1-888-772-9682 or visit www.aetna.com/docfind/custom/avp.
*Discount programs provide access to discounted prices and are not insured benefits.
Informed Health® Line
Aetna's Informed Health® Line gives you and your family access to registered nurses 24 hours a day, 7 days a week. This tollfree line connects you to a team of nurses experienced in providing information on a variety of health topics. Informed Health
Line nurses use the Healthwise® Knowledgebase to provide information about health issues, medical procedures and
treatment options, and help you and your family communicate more effectively with your doctors. You can also choose to listen
to certain health topics of interest through Aetna's new audio health library, which is available in English and Spanish. Contact
Aetna's Informed Health Line at 1-800-556-1555.
Employee Assistance Program
Aetna's Employee Assistance Program helps you and your family manage stress and balance work and life. Resources related
to emotional support, childcare, and legal and financial guidance are available by telephone and online.
Services also include consultation, information, education and referral services in connection with:
• parenting
• adoption
• grandparent as parent
• childcare and summer care
• temporary back-up care
• special needs
• high-risk adolescents
• adult care and elder care
• mental health
• academic services
• home improvement
• pet care
• consumer information
• legal services
• financial counseling
• child safety information
• pre-natal information
These services are convenient and confidential, available 24 hours a day, 7 days a week by calling 1-888-AETNA-EAP (1-888238-6232) or visiting www.AetnaEAP.com.
08/16/2011
Benefits Summary
Page 7
801920
Hospital and Medical Indemnity Exclusions and Limitations
This plan does not cover all health care expenses and has exclusions and limitations. Members should refer to their booklet
certificate 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 may contain exceptions to this list based on state
mandates or the plan design purchased.
Hospital and Medical Indemnity Exclusions:
• All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents.
• Cosmetic surgery, including breast reduction.
• Custodial care.
• Donor egg retrieval.
• Experimental and investigational procedures.
• Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies.
• Nonmedically necessary services or supplies.
• Reversal of sterilization.
No benefit is paid for or in connection with the following stays or visits or services:
• Those received outside the United States
• Those for education, special education or job training, whether or not given in a facility that also provides medical or
psychiatric treatment.
Terms defined
A service or supply is medically necessary if it is determined by Aetna to be appropriate for the diagnosis, care or treatment
of the disease or injury involved. See the plan documents for the complete definition
Inpatient charges are all charges incurred when you are admitted as an inpatient at a hospital or other inpatient facility.
Outpatient charges are charges billed for services and supplies provided at doctors' offices, free-standing clinics and
outpatient facilities. They also include charges at a hospital when you are not admitted as an inpatient, including emergency
room charges.
A Negotiated Charge is the maximum amount that a preferred provider has agreed to charge for a covered visit, service, or
supply. After your plan limits have been reached, the provider may require that you pay the full charge rather than the
negotiated charge.
Preventive visits are those visits to the doctor for services that are not for the purpose of diagnosing or treating an injury or
disease. Some common types of preventive visits are annual physical exams, gynecological exams, well-baby or well-child
visits, mammograms, some cancer screenings, and bone mass density measurements. Included as part of the preventive
visit are x-rays, lab and other tests, and materials for the administration of immunizations and testing for tuberculosis.
Your plan might not offer a preventive visit(s) benefit. Please refer to the benefits chart in this Benefits Summary. Some
federal and state laws mandate certain preventive exams that are to be covered by, or in addition to, this benefit if offered
under your plan. If a preventive visit(s) benefit is not offered under your plan (see the benefits chart), these mandates will be
covered by other benefits under your plan. Please refer to the plan documents for more information.
08/16/2011
Benefits Summary
Page 8
801920
Other available benefits:
Hospital Indemnity
Lump-sum benefit
$1,000 for one stay in the hospital as an inpatient per coverage year; plus
Daily benefit
$100 per day, for up to 100 days that you are an inpatient in a hospital per
coverage year.
This benefit applies if you or a covered dependent are admitted to the hospital as an inpatient.
Hospital Indemnity Limitations and Exclusions:
certificate to determine which health care services are covered and to what extent. The same limitations and exclusions apply
as those listed for the Hospital and Medical Indemnity and/or dental coverage (if offered under your plan). However, your
plan may contain exceptions to this list based on state mandates or the plan design purchased.
Vision Care
Eye Exams
Reimbursements of up to $100 every 12 months for an exam, frames, lenses,
or contact lenses.
Fees for other services must be paid by you. Benefit period is 12 consecutive months beginning on the later of your effective
date or your most recent eye exam covered under this plan.
When you enroll in Vision Care coverage, you also receive:
Aetna VisionSM Discounts*
Aetna VisionSM Discounts uses the nationwide EyeMed Select Network of
vision care providers to offer you and your family glasses, contact lenses,
nonprescription sunglasses, contact lens solutions and other eye care
accessories at discounted prices. Plus, you can receive discounts on eye
exams and LASIK eye surgery. For exams and eyewear call 1-800-7938616. For contacts call 1-800-391-5367. For LASIK customer service call 1800-422-6600. You can also locate a local provider by visiting
www.aetna.com/docfind/custom/avp.
*Discount program provides access to discounted prices and is not an insured benefit. This discount arrangement may not be
available to Illinois residents.
Vision Care Exclusions:
certificate 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 may contain exceptions to this list based on state
mandates or the plan design purchased.
• Orthoptic vision training, subnormal vision aids, any associated supplemental testing.
• Medical and/or surgical treatment of the eyes or supporting structure.
• Any eye or vision examination, or any corrective eyewear, required by an employer as a condition of employment.
08/16/2011
Benefits Summary
Page 9
801920
Short Term Disability (STD)
Benefit Period
Weekly benefits for up to 6 months while you are disabled.
Benefit Amount
50% of base pay received from the employer that sponsors this program
(includes reported tips, but not overtime) up to $125 maximum weekly
benefit.
Waiting Period
Benefits begin after 14 days (plan pays immediately if hospitalized).
Coverage for employee only; coverage not available in California, Hawaii, New Jersey, New York, Rhode Island, and Puerto
Rico.
Short Term Disability Exclusions:
This plan does not cover all circumstances and has exclusions and limitations. Members should refer to their booklet
certificate to determine which circumstances are covered and to what extent. The following is a partial list of circumstances
that are generally not covered . However, your plan may contain exceptions to this list based on state mandates or the
plan design purchased.
• Attempted suicide, while sane or insane, or intentional self-inflicted injury or sickness, unless as the result of a medical
condition.
• Commission of or attempt to commit an act which is a felony in the jurisdiction in which the act occurred.
• Substance abuse.
• Occupational injury or sickness.
08/16/2011
Benefits Summary
Page 10
801920
Questions and answers about Hospital and Medical Indemnity, or Hospital Indemnity (if offered)
Hospital and Medical Indemnity, or Hospital Indemnity, if offered, are fixed indemnity plans. How does a fixed
indemnity plan work?
Fixed indemnity plans have no copays, deductibles, or coinsurance. A fixed indemnity plan pays a fixed amount per service,
with limits on the number and types of services. Once you have used up your number of services, the plan will no longer pay
for that kind of service. Because the plan pays a fixed amount, you may owe the provider more than the plan pays. If you
choose a preferred (in network) provider, then you may pay less, because the provider may accept payment for the negotiated
charge. Before you enroll in the plan, please read the benefits chart in the previous pages carefully to understand what this
plan will pay.
How does this fixed indemnity plan differ from a traditional major medical health plan?
There are important differences in what the plan will pay and what the premium costs. Both types of plans pay benefits for
many types of services and supplies. However, this fixed indemnity insurance plan pays a fixed amount per type of service
and places limits on how many times it will pay for each category of service or supply. Once you have used up the limits on
specific benefits, the plan will not pay any more. And unlike most major medical plans, this fixed indemnity insurance plan
does not have catastrophic coverage or a limit on your out-of-pocket expenses. This means that you may have large out-ofpocket costs if you have a serious or chronic medical condition. Because traditional major medical health plans provide more
coverage, they cost more.
How does this fixed indemnity plan differ from a limited benefits plan?
If you were previously enrolled in a limited benefits insurance plan, it is important to understand how a fixed indemnity plan is
different. A limited benefits plan pays a percentage of the charge (coinsurance) up to a maximum amount, and may
occasionally have limits on the number of services. A fixed indemnity plan pays a fixed amount per service regardless of the
amount of the charge, with limits on the number of some services. A limited benefits plan may have copays and deductibles.
This fixed indemnity plan has no copays, deductibles, or coinsurance.
Does this fixed indemnity plan provide creditable coverage or COBRA continuation coverage?
Unlike a traditional major medical health plan or an Aetna limited benefits plan, this fixed indemnity plan does not provide
creditable coverage under HIPAA and does not offer COBRA continuation coverage.
What will I pay up front when I go to a healthcare provider?
A provider may require that you pay all charges in advance, and it would be up to you to submit a claim for reimbursement for
any charges the plan may pay.
What if I don’t understand something I’ve read here, or have more questions?
Please call us. We want you to understand these benefits before you decide to enroll. You may reach one of our Customer
Service representatives Monday through Friday, 8 a.m. to 8 p.m. Eastern Time, by calling toll free 1-888-772-9682. We’re
here to answer questions before and after you enroll.
08/16/2011
Benefits Summary
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801920
THIS PLAN DOES NOT PROVIDE COMPREHENSIVE MEDICAL COVERAGE. IT IS AN INDEMNITY
POLICY AND IS NOT INTENDED TO COVER ALL MEDICAL EXPENSES. THIS PLAN IS NOT
DESIGNED TO COVER THE COSTS OF SERIOUS OR CHRONIC ILLNESS. IT CONTAINS SPECIFIC
LIMITS THAT WILL BE PAID FOR MEDICAL SERVICES WHICH MAY NOT BE EXCEEDED. IF THE
COST OF SERVICES EXCEEDS THOSE LIMITS, THE BENEFICIARY AND NOT THE INSURER IS
RESPONSIBLE FOR PAYMENT OF THE EXCESS AMOUNTS. THE SPECIFIC LIMITS ARE
DESCRIBED IN THIS BENEFITS SUMMARY.
ATTENTION MASSACHUSETTS RESIDENTS: As of January 1, 2009, the Massachusetts Health Care Reform Law requires
that Massachusetts residents, eighteen (18) years of age and older, must have health coverage that meets the Minimum
Creditable Coverage standards set by the Commonwealth Health Insurance Connector, unless waived from the health
insurance requirement based on affordability or individual hardship. For more information call the Connector at 1-877-MAENROLL (1-877-623-6765) or visit the Connector website (www.mahealthconnector.org). THIS POLICY, ALONE, DOES
NOT MEET MINIMUM CREDITABLE COVERAGE STANDARDS. If you have questions about this notice, you may contact
the Division of Insurance by calling 617-521-7794 or visiting its website at www.mass.gov/doi.
This material is for information only and is not an offer or invitation to contract. Insurance plans contain exclusions and
limitations. Providers are independent contractors and are not agents of Aetna. Provider participation may change without
notice. Aetna does not provide care or guarantee access to health services. 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. Aetna receives rebates from drug manufacturers that may be taken into account in
determining Aetna's Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered
prescriptions. Discount programs provide access to discounted prices and are not insured benefits. Information is believed to
be accurate as of the production date; however, it is subject to change.
Insurance plans are underwritten by Aetna Life Insurance Company (referred to as "Aetna") and administered by
Aetna or Strategic Resource Company (SRC, an Aetna company).
For OK residents only, policy forms issued include GR-9/GR-9N, GR-29/GR-29N, GR96172, and GR96173.
08/16/2011
Benefits Summary
Page 12
Clean-Tech Company/Witt, Fiala, Flannery and
Associates, Inc. dba WFF Facility Services
801920
(formerly Aetna Affordable Health Choices®)
Enrollment/Change Request
Insurance plans are underwritten by Aetna Life Insurance Company (referred to as "Aetna")
and administered by Aetna or Strategic Resource Company (SRC, an Aetna company).
Instructions: Read and fill out the Enrollment/Change Request (all pages). Make a copy for yourself. Give the original to your employer.
INFORMATION ABOUT YOU Complete all information.
Print your name (first, middle initial, last)
Social Security Number
Home address
Home phone
Apartment number
Work phone
City
Email address
Date of birth (MM/DD/YYYY)
State
Sex
(
)
(
)
ACTION YOU WANT TO TAKE Check the box next to the action you want to take.
 Male
 Female
Zip code
Primary language spoken (Idioma principal)
I am not currently enrolled and I want to…
 Enroll in the coverage choices selected below.
 Decline this opportunity to participate.
I am currently enrolled and I want to…
 Make changes to my current coverage choices (add, increase, drop, decrease) as selected below.
All of my other coverage choices will remain the same as previously elected.
(If outside of an open enrollment, see “Making Changes Outside of an Open Enrollment.”)
 Update my personal and/or my dependent information.
 Drop all of my current coverage choices.
Your payroll deductions will be taken before taxes are taken. (STD deductions will be taken after taxes.)
YOUR COVERAGE CHOICES Check() the box for the level of coverage you want.
Coverage type
Coverage level
Medical and Hospital
Indemnity
You may enroll in one medical
option only.
 No Medical and Hospital Indemnity
Option 1
 Yourself only........................................................................................................................................................................ $
 Yourself plus one................................................................................................................................................................. $
 Yourself and family.............................................................................................................................................................. $
Option 2
 Yourself only........................................................................................................................................................................ $
 Yourself plus one................................................................................................................................................................. $
 Yourself and family.............................................................................................................................................................. $
Weekly cost
18.78
46.95
65.73
28.16
70.40
98.56
Hospital Indemnity




No Hospital Indemnity
Yourself only........................................................................................................................................................................ $ 3.80
Yourself plus one................................................................................................................................................................. $ 7.60
Yourself and family.............................................................................................................................................................. $ 11.40
Vision




No Vision
Yourself only........................................................................................................................................................................ $
Yourself plus one................................................................................................................................................................. $
Yourself and family.............................................................................................................................................................. $
Short Term Disability (STD)
YOUR AUTHORIZATION
1.00
1.70
2.40
 No Short Term Disability
 Yourself only........................................................................................................................................................................ $ 3.50
Coverage is not available if you work in California, Hawaii, New Jersey, New York, Rhode Island, and Puerto Rico.
You must sign and date this Enrollment/Change Request for all new enrollments or coverage changes.
I represent that all information supplied in this Enrollment/Change Request is true and complete to the best of my knowledge and/or belief. I have read and agree to the
Conditions of Enrollment on the reverse side of this Enrollment/Change Request.
Your signature
Today’s date (MM/DD/YYYY)
EMPLOYER GROUP INFORMATION This section is to be completed by your employer.
Employee ID
Hire date (MM/DD/YYYY)
Location or site code
Authorized signature
Pay type
Total deduction ($)
Effective date (MM/DD/YYYY)
Title
Today’s date (MM/DD/YYYY)
This Enrollment/Change Request is not proof of coverage.
12.08.303.1-MO
801920 LB
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INFORMATION ABOUT YOU Repeat your name and Social Security number here.
Print your name (first, middle initial, last)
INFORMATION ABOUT YOUR DEPENDENTS List the dependents for whom you are adding/changing/removing coverage.
If you have more dependents, write down their information on a separate sheet and attach it to this Enrollment/Change Request.
 Add
Print dependent’s name (first, middle initial, last)
 Change
 Remove
Sex
Date of birth
Enrolled in:  Medical and Hospital Indemnity /  Hospital Indemnity /
 Male /  Female
 Vision
Relationship:
 Spouse
 Child
 Other (Specify): ______________________________________________
Address (if different than yours)
 Add
 Change
 Remove
City
State
Sex
Zip code
Date of birth
 Vision
Relationship:
 Spouse
 Child
 Other (Specify): ______________________________________________
 Add
 Change
 Remove
City
State
Sex
Zip code
Date of birth
 Vision
Relationship:
 Spouse
 Child
 Other (Specify): ______________________________________________
City
State
Zip code
MAKING CHANGES OUTSIDE OF AN OPEN ENROLLMENT Please read below to see if you are able to make changes to your coverage.
If your deductions are taken before taxes are taken out of your pay, you can change your coverage during
the plan year only if you have a Qualifying Life Event (QLE). If your deductions are taken after taxes,
you may drop or decrease coverage at any time. QLEs fall under one of these two categories:
Loss of Other Coverage (LOC): If you previously declined health coverage because you or your
dependents were already covered under another health plan and you or your dependents have lost that
other coverage, you may be able to enroll yourself and your dependents. If you had a recent LOC, go to
the list on the right and check the box next to your LOC and supply the date of the LOC.
Family Status Change (FSC): Whether you are currently enrolled or previously declined coverage, you
may be able to add or increase, drop or decrease coverage when you experience certain FSC events. If
you had a recent FSC, go to the list on the right and check the box next to your FSC and supply the date
of the FSC.
Next, complete the rest of this Enrollment/Change Request. When finished, make a copy and submit it to
your employer with your documentation attached. You must submit this Enrollment/Change Request,
together with documentation, to your employer within 30 days of the LOC/FSC.
Loss of Other Coverage (LOC):
 Divorce, legal separation or death
 Termination of employment of a dependent
 Reduction of a dependent’s hours
 Termination of your or your dependents’ COBRA rights
 Loss of employer’s contribution to spouse’s coverage
 Dependent child losing eligibility as a dependent
 Other loss of coverage
Family Status Change (FSC):
 Divorce, legal separation or death
 Marriage
 Birth or adoption of a dependent
 Other
Date of LOC or FSC (mm/dd/yyyy)
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801920 LB
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CONDITIONS OF ENROLLMENT Applicant acknowledgments and agreements
On behalf of myself and the dependents listed on this Enrollment/Change Request, I agree to or with the following:
1. I acknowledge that by enrolling in an Aetna plan coverage is underwritten by Aetna Life Insurance Company (referred to as "Aetna") 151 Farmington Avenue,
Hartford, CT 06156 and administered by Aetna or Strategic Resource Company (SRC, an Aetna company), 221 Dawson Road, Columbia, SC 29223.
2. I authorize deductions from my earnings for any contributions required for coverage and I agree to make any necessary payments as required for coverage.
3. I understand and agree that this Enrollment/Change Request may be transmitted to Aetna or its agent by my employer or its agent. I authorize any physician, other
healthcare professional, hospital or any other healthcare organization ("Providers") to give Aetna or its agent information concerning the medical history, services or
treatment provided to anyone listed on this Enrollment/Change Request, including those involving mental health, substance abuse and HIV/AIDS. I further authorize
Aetna to use such information and to disclose such information to affiliates, providers, payors, other insurers, third party administrators, vendors, consultants and
governmental authorities with jurisdiction when necessary for my care or treatment, payment for services, the operation of my health plan, or to conduct related
activities. I have discussed the terms of this authorization with my spouse and competent adult dependents and I have obtained their consent to those terms. I
understand that this authorization is provided under state law and that it is not an "authorization" within the meaning of the federal Health Insurance Portability and
Accountability Act. This authorization will remain valid for the term of the coverage and so long thereafter as allowed by law. I understand that I am entitled to
receive a copy of this authorization upon request and that a photocopy is as valid as the original.
4. The plan documents will determine the rights and responsibilities of member(s) and will govern in the event they conflict with any benefits comparison, summary or
other description of the plan. Any direct conflict between this form and the plan documents will be resolved according to the terms which are most favorable to the
member.
5. I understand and agree that with the exception of Aetna Rx Home Delivery®, all participating providers and vendors are independent contractors and are neither
agents nor employees of Aetna. 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.
6. Misrepresentation: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance
or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits
a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits
a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Attention Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
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Material order form
STEP 1: Circle the quantity of each item you want to order.
Materials
Quantity (circle quantity)
Enrollment Kit, English
25
50
75
100
Enrollment Kit, Spanish
25
50
75
100
Poster, English
1
2
5
10
Poster, Spanish
1
2
5
10
Material Order Form
1
5
10
20
Termination Roster
10
20
30
40
Other (describe):
Enter quantity:
Please note: Claim forms can be found at www.aetna.com/docfind/custom/avp.
STEP 2: Provide the requested client information below
Group number:
Corporate name:
DBA:
Requestor’s name:
Street address:
City, State, Zip:
Telephone number:
STEP 3: Send this completed form to:
SRC, an Aetna company
P.O. Box 14079
Fax: 859-455-8650
SRC INTERNAL USE ONLY
Delivery method:
 UPS Ground
 Other (describe):
Date:
By:
Tracking No.:
Please ensure the information captured in this form is forwarded electronically to ‘SRC - Implementation Coordinators’
12.09.108.1 (12/10)
LB
As a manager and leader, it’s up to you to make sure employees know about their
chance to enroll in coverage. Here are the key points that you and your employees
need to know about the enrollment process.
Eligible employees
Only eligible employees and their eligible dependents can enroll in the plan. The
following employees are eligible to enroll:
All full-time General Cleaners and all other full-time employees who are not
eligible for another medical plan offered by Clean-Tech Company are eligible to
enroll after completing 90 days of service.
Open enrollment
Please use the posters, tent cards, and DVD in your enrollment support packet to
help tell employees about open enrollment. Unless employees experience a
qualifying life event, they can enroll only during defined open enrollment periods.
Therefore, it is important that you tell employees when open enrollment
occurs.
 Open enrollment begins September 1 and ends September 30, 2011
 Newly hired employees have 90 days from the date they become eligible to
enroll
How to enroll
1. Make sure your employees receive their enrollment kit before enrolling.
 Enrollment kits will be shipped to your location. Please make sure that each
employee receives one.
 Enrollment kits can also be viewed online at www.aetna.com/src. Employees
can follow the links to log in, entering user name 801920 and password
AAHC. Then go to the Document Library.
2. Encourage employees to review their enrollment kit and make a decision
by the deadline. We want everyone to make an informed decision, so reading
the enrollment kit is important.
3. Your employees can enroll by filling out and turning in an Enrollment/Change
Request form.
12.40.102.1 CleanTechC (08/11)
Coverage options
The insurance coverage offered:
 Medical / Hospital and Medical Indemnity
 Hospital indemnity
 Vision Care
 Short Term Disability (for employee only, not dependents)
For more information, please read the manager’s guidebook that
came in your enrollment support packet. Please review an employee enrollment kit
for specific details on the plan.
Insurance plans are underwritten by Aetna Life Insurance Company (referred to as "Aetna")
and administered by Aetna or Strategic Resource Company (SRC, an Aetna company). This
material is for information only. Plans contain exclusions and limitations. Information is believed to be
accurate as of the production date; however, it is subject to change. Policy forms issued in OK include GR9/GR-9N and/or GR-29/GR-29N.
©2011 Aetna Inc.
12.40.102.1 CleanTechC (08/11)
List Bill
Administration Guide
You can make enrollment a success
Collect completed Enrollment/Change Request forms from your employees.
Complete the employer information section on each form and make a copy
for your payroll processing.
How to start coverage
Send the completed Enrollment Change Request forms to SRC to start
coverage.
Send enrollment materials to:
P.O. Box 981119
El Paso, TX 79998-1119
Fax 859-455-8650
Insurance plans are underwritten by Aetna Life Insurance Company
(referred to as "Aetna") and administered by Aetna or
Strategic Resource Company (SRC, an Aetna company)
AVFBP
15/30
12.05.106.1 A (06/11)
Open enrollment
Open enrollment periods are
times when employees are given
the opportunity to enroll
themselves and their eligible
dependents.
An employee’s first open
enrollment occurs after he or
she first becomes eligible. All
eligible employees are later
offered the chance to enroll at
least once per year, including
those who previously turned
down coverage.
Employee Q&A
Contact
information
Contact information
Answers to common employee questions
Enrollment
Send enrollment forms to:
P.O. Box 981119
El Paso, TX 79998-1119
Fax 859-455-8650
Can the employee enroll at any time?
No. An employee may enroll only during an open enrollment period (such as
an annual open enrollment period or a new hire enrollment period).
An employee must experience a Qualifying Life Event if he or she wants to
enroll outside of these enrollment periods.
Claims
Claim forms are available from
www.aetna.com/docfind/
custom/avp
Mail claims to:
Attn: Claims Department
P.O. Box 14079
Need additional materials?
Please call 1-888-772-9682.
Or, log on to
www.aetna.com/src and
follow the links to the
Document Library. Use your
group number as your
username. Your password is
AAHC.
Questions?
For more information please call
us toll free at 1-888-772-9682.
Can an employee get a refund of premiums if he or she drops
coverage after a deduction has been taken?
No. Premiums paid are non-refundable.
Are benefits coordinated?
No. Usually, the plans pay regardless of other coverage. Since the plans
specifically exclude expenses from on-the-job injury or sickness, the plans
would not pay when Workers’ Compensation or similar coverage is available.
Will members get ID cards?
Employees choosing medical and/or dental coverage (if offered) for the first
time will get plastic member identification (ID) cards. Until the plastic IDs
arrive, members should use the temporary member ID contained in the
enrollment kit. This ID is valid after the member's coverage begins. For
questions about ID cards, call 1-888-772-9682.
When does coverage end?
An employee’s coverage will end when an Enrollment Change/Request form
to drop coverage or a Termination Roster has been forwarded to SRC for
processing. Dependent coverage ends when the employee’s coverage ends
or when the dependent is no longer eligible.
More questions?
Please review the Questions and Answers document found within the
enrollment kit. Or, you may call us toll free at 1-888-772-9682.
2
Changing
coverage
QLEs
Changing coverage after open enrollment
Increasing coverage
A Qualifying Life Event (QLE) is required to increase coverage or enroll
outside of an open enrollment period.
Deductions after taxes
Coverage for which premiums are deducted after taxes may be dropped or
reduced by the employee at any time without a QLE. A QLE is required to
increase coverage outside of an open enrollment period.
Deductions before taxes
For any coverage deducted before taxes, a QLE is required to drop, reduce or
increase coverage, or to enroll outside of an enrollment period.
Qualifying Life Events
(QLEs)
Generally, these are Family
Status Changes (FSC) or events
that result in Loss of Other
Coverage (LOC).
Family Status Changes (FSC)
Due to:
■ Divorce, legal separation or
death
■
How to change coverage
The employee must fill out an Enrollment/Change Request Form, make a
copy for his or her records and return the completed form to you. Record
the employee’s changes and submit the Enrollment/Change Request form to
SRC. You may fax forms to 859-455-8650.
■
■
Birth or adoption of a
dependent
Other
Loss of Other Coverage (LOC)
Due to:
■ Divorce, legal separation or
death
■
■
■
■
■
■
3
Marriage
Termination of employment of
a dependent
Reduction of a dependent’s
working hours
Termination of employees or
employees dependent’s
COBRA rights
Loss of employers contribution
to spouse’s coverage (or to
domestic partner’s coverage if
domestic partner coverage is
offered under your plan)
Dependent child losing
eligibility as a dependent
Other loss of coverage
Billing rules
Terminations
Premium
payments
Premium payments
Payment can be made by check
or electronic funds transfer
(EFT).
Billing rules
To set up EFT, please request a
Premium transmittal for self bill
clients from your Account
Manager.
The billing cycle begins on the first day of the month for all employees
covered during the previous month. On or about the 15th of the month,
SRC will send an invoice reflecting additions, changes and terminations for
the current month. The invoice will reflect the amount due for the coverage
extended. All additions, changes, and terminations received after the 10th
of the month will be effective the following month.
To pay by check, make checks
payable to SRC/Aetna.
You are responsible for remitting the full amount due as reflected by the
invoice. Payment is due upon receipt of invoice.
Be sure to include your group
name and number.
Send payment upon receipt of
your invoice to:
Aetna, Inc.
PO Box 536919
Atlanta, GA 30353-6919
15/30 wash rule
Coverage for an employee who terminates employment from the 16th
through the end of the month will be billed as a full month. Coverage for
an employee who terminates before the 16th will not be billed for the 1st
through the date of termination and will not be included in the current
invoice.
Terminations
Termination of coverage is effective on the day in which the employee
terminates employment.
Complete a Termination Roster when an enrolled employee terminates
during the month and send this Termination Roster to SRC with your
monthly package. All appropriate billing corrections will appear on your
next month’s invoice.
It is important that you record all terminations right away and send with
your next monthly package. SRC will credit up to the cost of only 60 days
coverage if we receive late notice of the termination.
4
Life conversion
Life conversion
Employees who are covered for term life insurance must be given the right
to convert their coverage to a policy of individual insurance when coverage
ceases because they terminate employment, when they are no longer in a
class eligible for term life insurance coverage, or because of age, pension or
retirement. Dependent life insurance may be converted when the employee
terminates employment or when the employee is no longer in a class eligible
for term life insurance coverage, and only in those situations.
During the 31 days immediately following one of the above events, the
person may contact SRC to convert his or her coverage to a Guaranteed
Cost Whole Life Insurance policy, which is a cash-value policy. If the person
does not do this within 31 days, the application will be denied. Some
states allow more than 31 days for conversion in certain
circumstances. Please refer to the Conversion section of your plan
documents for the specific terms that apply to your group plan.
If the employee terminates employment due to total disability and applies for
extension under the Premium Waiver provision, he or she must submit the
conversion application and the first premium payment within 63 days from
the date coverage terminates. If the employee is subsequently approved for
Premium Waiver coverage, the conversion policy will be canceled, and all
premium payments will be returned.
In plan discontinuance situations, employees who have been continuously
insured for a period of five years are entitled to convert a designated amount
to an individual policy, up to a maximum of $10,000 depending on the law
of the state where the contract is issued. If the employee has not been
continuously insured for the time specified in the plan documents, the
employee (or former employee) will not be eligible to convert this coverage.
If the person dies during the 31-day application period and before their
individual policy goes into effect, the amount payable under the group plan
will be limited to the maximum that could have been converted. This applies
even if the person has not applied for the individual policy.
The above terms apply in most instances; however, they may vary from state
to state. Please refer to the Conversion section of your plan documents for
the specific terms that apply to your group plan.
5
If your group plan
includes term life
insurance, an employee
may generally be
allowed to convert his or
her coverage to a policy
of individual insurance
upon certain qualifying
events.
Applying for term
life conversion
As the employer, you are
responsible for ensuring
that employees and any
eligible dependents
know they can apply for
a policy of individual
insurance.
Applying for a policy of individual insurance
Applying for term life conversion
Upon contacting SRC, an employee or their dependent will be given the
‘Application For Conversion of Group Term Life Insurance’ when their term
life coverage ceases due to one of the events previously explained. The
employee (or former employee) or their dependent is responsible for
completing this section and sending the form to the address shown on the
form.
Insurance plans are underwritten by Aetna Life Insurance Company (referred to as "Aetna") and administered by Aetna or
Strategic Resource Company (SRC, an Aetna company)
Insurance plans contain exclusions and limitations. See plan documents for a complete description of benefits, exclusions, limitations and
conditions of coverage. Information is believed to be accurate as of the production date; however, it is subject to change.
AVFBP
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6
Member Reference Guide
Facts about the Plan
Group Name: ........................................................... Clean-Tech Company/Witt, Fiala, Flannery and Associates, Inc. dba WFF Faculty Services.
Group Number: ....................................................... 801920
Group Insurance Policy Number:............................... AMA120002010
Eligible Employees:................................................... All full-time General Cleaners and all other full-time employees who are not eligible for another
medical plan offered by WFF Facility Services.
Eligibility: ................................................................. Employees must enroll during the 90 day waiting period.
Your Coverage Begins:............................................. The first day of the month after completing the 90 day waiting period, provided you are
eligible.
Plan Name: .............................................................. Group Benefits Program
Welfare Plan Type .................................................... Employee Welfare Benefit plan
Plan Number: ........................................................... 501
Coverage Year Begins: ............................................. October 1
Plan Fiscal Year End:................................................. September 30
Plan Sponsor: ........................................................... Clean-Tech Company/Witt, Fiala, Flannery and Associates, Inc. dba WFF Facility Services
211 South Jefferson Avenue
St. Louis, MO 63103
Telephone: 314-652-2388
Plan Administrator: .................................................. Director of Risk Management
Clean-Tech Company/Witt, Fiala, Flannery and Associates, Inc. dba WFF Facility Services
211 South Jefferson Avenue
St. Louis, MO 63103
Telephone: 314-652-2388
Employer Identification Number (EIN): ...................... 43-1044093
Underwriter of the coverage(s) issued under the plan:
Insurance plans: .................................................. Aetna Life Insurance Company
151 Farmington Avenue
Hartford, Connecticut 06156
Aetna Affiliate:.................................................... Strategic Resource Company (SRC)
221 Dawson Road
Columbia, SC 29223-1704
P.O. Box 14079, Lexington, KY 40512-4079
Benefits/Claims:................................................... 1-888-772-9682
DocFind Online Provider Directory:....................... 1-888-772-9682................................ ....................... www.aetna.com/docfind/custom/avp
Provider(s) of the discount program(s) within the plan:
Prescription Drug Discount Program: ................... Aetna Pharmacy Management
Members/Providers: ........................................ 1-800-AETNA-Rx (1-800-238-6279) ...........................www.AetnaPharmacy.com
Eyewear Discount Program: ................................. Aetna VisionSM Discounts
Exam and Eyewear: ........................................ 1-800-793-8616 (Weekdays 9 a.m. - 9 p.m., Saturday 9 a.m. - 5 p.m. ET)
LASIK Customer Service:................................. 1-800-422-6600 (Weekdays 8 a.m. - 9 p.m., Saturday 9 a.m. - 6 p.m. ET)
Contacts: ....................................................... 1-800-391-5367........................................................www.aetna.com/docfind/custom/avp
Informed Health® Line:............................................. 1-800-556-1555
Employee Assistance Program: ................................. 1-888-AETNA-EAP (1-888-238-6232)........................ www.AetnaEAP.com
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12.03.397.1 CleanTechC (08/11)
Understanding the Plan
You can only be covered for the plan selection(s) for which (1) you enrolled and (2) premium has been paid. Please check your paycheck stub to
confirm that the deduction(s) for your election(s) has/have begun and that the amount agrees with what you had figured for your selection(s),
based on its/their cost. If you have any questions about your payroll deductions, contact your benefits department.
Extra-Territorial Information
Some states require that certain benefits or provisions be provided to their residents regardless of where the group insurance policy that covers
those residents is issued. If you are a resident of one of those states, your state's requirements will apply to you in place of the benefits or
provisions in your policy when those requirements provide a greater benefit or right than described in your policy.
Filing a Claim
How do I file a claim? Obtain a claim form for the type of claim you are filing by:
 Logging on to www.aetna.com/src or www.aetna.com/docfind/custom/avp
 Calling Claims Customer Service at 1-888-772-9682 Monday through Friday, 8:00 a.m. to 8:00 p.m. ET
 Writing to Strategic Resource Company, Attn: Claims Department, P.O. Box 14079, Lexington, KY 40512-4079
These claim forms contain instructions on how to fill them out (some forms include sections for your employer to fill out). If a member dies as the
result of an accident or illness, their beneficiary should apply for the insurance benefit as soon as possible.
Send completed forms to Strategic Resource Company, Attn: Claims Department, P.O. Box 14079, Lexington, KY 40512-4079. Your doctor or
dentist may prefer to file a claim for you using his or her own form. But if you have a claim, you must send in a signed claim form of the type
utilized by this plan. This will help ensure prompt processing of your claim. If your plan offers Hospital Indemnity coverage, proof of in-patient
hospitalization must be provided to be eligible for this insurance. Examples of acceptable proof would be an in-patient UB04 hospital bill, or a
statement from your attending physician that you were confined as an in-patient in a hospital, the length of your stay and the reason (diagnosis)
that you were confined. If you have medical expenses resulting from an accident, you must provide full details of the accident on your completed
claim form. The insurer reserves the right to require a medical examination at its expense. For Customer Service call 1-888-772-9682, Monday
through Friday, 8:00 a.m. to 8:00 p.m. ET.
What if I have a Certificate of Creditable Health Coverage from a former employer? If you submit it and it is approved, your pre-existing
Waiting Period can be reduced, even eliminated. Make a copy of your certificate and send it to the claims address shown above. If you have lost
your certificate, you may request another from the former employer.
How do I (or a beneficiary) appeal a denied claim? If all or a part of your claim is denied, you or the member’s beneficiary will be provided a
written explanation by the insurance company which will include:




The specific reasons for the denial;
Reference to the pertinent plan provisions upon which the denial is based;
A description of any additional information you might be required to provide and explanation of why it is needed; and
An explanation of the plan's claim review procedure.
You, your beneficiary (when an appropriate claimant), or a duly authorized representative may appeal any denial of a claim for benefits by filing a
written request for a full and fair review to the insurance company. In connection with such a request, documents pertinent to the administration
of the plan may be reviewed, and comments and issues outlining the basis of the appeal may be submitted in writing to Strategic Resource
Company, Attn: Claims Department, P.O. Box 14463, Lexington, KY 40512-4463. You may have representation throughout the review procedure.
A request for a review must be filed by 180 days after receipt of the written notice of denial of a claim. The full and fair review will be held and a
decision rendered by the insurance company no longer than 60 days (45 days for term life or short term disability claims, if included in your plan)
after receipt of the request for the review.
In the case of a claim involving urgent care, you will be notified of the plan's benefit determination on review as soon as possible, taking into
account the medical exigencies, but not later than 72 hours after receipt of your request of an adverse benefit determination by the plan. A claim
involving urgent care is any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent
care determinations: (a) could seriously jeopardize the life or health of the claimant to regain maximum function, or (b) in the opinion of a physician
with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the
care or treatment that is the subject of the claim.
If there are special circumstances, the decision will be made as soon as possible, but not later than 120 days (90 days for term life or short term
disability claims, if included in your plan) after receipt of the request for the review. If such an extension of time is needed, you will be notified in
writing prior to the beginning of the time extension period. The decision after your review will be in writing and will include specific reasons for the
decision as well as specific references to the pertinent plan provisions on which the decision is based.
Insurance plans are underwritten by
Aetna Life Insurance Company (referred to as
"Aetna") and administered by Aetna or
Strategic Resource Company (SRC, an Aetna
company).
MRG: V-001 ED-001 (06/06)
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12.03.397.1 CleanTechC (08/11)
Planes voluntarios de Aetna
La inscripción abierta
comienza el
1 de septiembre
y termina el
30 de septiembre de
2011.
Preguntas y respuestas
Información de membresía que necesita saber
¿Recién contratado?
Tiene 90 días desde la
fecha de contratación
para inscribirse.
¿Cómo decido si este es el plan que me conviene?
Por favor lea la información en este paquete de inscripción, incluyendo el Resumen de
Beneficios, que detalla los beneficios, limitaciones, características y exclusiones del plan.
Considere el monto que pagará por las primas, como aparece en la Solicitud de inscripción o
cambio, y compare este plan con cualquier otra opción de cobertura médica que pueda tener.
Si tiene cualquier pregunta o necesita información adicional, por favor llámenos al número de
teléfono sin cargo 1-888-772-9682.
Si no se inscribe
ahora, no podrá
inscribirse hasta el
próximo período de
inscripción abierta, a
menos que tenga un
evento de vida
permisible.
¿Cómo funciona el plan de indemnización fija?
Los planes de indemnización fija no tienen copagos, deducibles ni coseguro. Un plan de
indemnización fija paga un monto fijo por servicio, con límites en el número y en los tipos de
servicios. Una vez que ha usado el número de servicios asignado, el plan ya no pagará por
ese tipo de servicio. Debido a que el plan paga una cantidad fija, usted podría deberle al
proveedor más de lo que el plan paga. Si opta por un proveedor preferido (que pertenece a la
red), podría tener que pagar menos porque el proveedor puede aceptar pago por la tarifa
negociada de la red. Antes de inscribirse en el plan, por favor lea el cuadro de beneficios de
las páginas anteriores detenidamente para entender lo que pagará este plan.
¿Quién puede participar?
All full-time General Cleaners and all other full-time employees who are not eligible for
another medical plan offered by WFF Facilty Service are eligible to participate after completing
90 days of service. Si usted es un empleado con derecho de inscribirse, también puede
inscribir a sus dependientes elegibles (excepto en el plan de Incapacidad a corto plazo). Sus
dependientes elegibles son su cónyuge legítimo y sus hijos desde su nacimiento hasta los 26
años de edad, hasta cualquier edad si son incapacitados y no pueden ganarse la vida, o hasta
que ya no puedan ser declarados como dependientes legalmente. La edad del dependiente y
las condiciones para calificar pueden variar por estado.
¿Cuándo comienza la cobertura?
La cobertura es vigente el primer día del mes después de su inscripción y después de que
usted haya completado su período de espera de 90 días.
¿Cuándo reinician los límites?
Los deducibles, montos máximos y límites anuales se suman a lo largo del
año de cobertura y luego reinician en la fecha de aniversario de su año de
cobertura el 1 de octubre.
Recorte su identificación temporal de miembro sobre las líneas entrecortadas.
¿Recibiré tarjetas de identificación?
Si selecciona la cobertura médica recibirá tarjetas de identificación del
miembro de plástico. Mientras recibe sus tarjetas de identificación de
plástico, por favor use la tarjeta de identificación temporal del miembro de
la parte inferior derecha. Esta tarjeta de identificación es válida una vez que
se inscribe y comienza su cobertura.
¿Cómo presento un reclamo?
Puede obtener formularios de reclamo en www.aetna.com/docfind/custom/avp,
llamando al número de teléfono sin cargo de SRC 1-888-772-9682, o
escribiendo a Strategic Resource Company, Attn: Claims Department,
P.O. Box 14079, Lexington, KY 40512-4079.
DOI
MEDICAL PPO
AETNA VOLUNTARY PLANS
BIN# 610502
EMPLOYEE NAME: _________________________________________________________________
AND COVERED DEPENDENTS
FOR MEMBER SERVICES CALL
1-888-772-9682
PAYOR NUMBER 57604 0039
AVFBP
12.03.359.2 CleanTechC (8/11)
RX
CLEAN-TECH COMPANY/WITT, FIALA, FLANNERY AND ASSOCIATES, INC.
DBA WFF FACILITY SERVICES
COMPANY NO.: 801920
www.aetna.com/docfind/custom/avp
HEALTH CARE PROVIDER: The person listed on the front of this card has
been enrolled under a fixed indemnity insurance plan sponsored by the
employer listed on the front of this card. Covered members are entitled
to benefits under the applicable plan, subject to exclusions and
limitations. This card does not guarantee coverage. For verification of
coverage, filing a claim or for questions other than the discount
programs, contact us at the number printed on the front of this card or
mail us at the address below.
INSURED: Network physicians, hospitals, and other health care providers
are independent contractors and are neither agents nor employees of Aetna
Life Insurance Company.
EMERGENCY URGENT CARE: Call your local emergency hotline (ex.911) or go
to the nearest emergency facility. For AETNA VISION DISCOUNTS call
1-800-793-8616. For LASIK call 1-800-422-6600. For CONTACTS DIRECT call
1-800-391-5367.
P.O. Box 14079
Aviso para todos los miembros sobre los servicios médicos:
Su parte del pago por servicios médicos puede basarse en el acuerdo entre
su plan médico y su proveedor. Bajo ciertas circunstancias, este acuerdo
puede permitir que su proveedor le facture por el monto equivalente a los
cargos de facturación normales del proveedor.
¿Tiene más preguntas?
Si necesita ayuda en cualquier idioma, llame sin cargo al 1-888-772-9682
de lunes a viernes de 8 a.m. a 8 p.m., hora del Este.
Los planes de seguro son suscritos por Aetna Life Insurance Company. Los planes son administrados por
Strategic Resource Company (SRC). Si bien se cree que la información dada en el presente documento es precisa a la fecha
de producción; está sujeta a cambios. Para los residentes de Oklahoma únicamente, los formularios de póliza emitidos incluyen
GR-9/GR-9N, GR-29/GR-29N, GR96172, y GR96173.
AVFBP
12.03.359.2 CleanTechC (8/11)
Clean-Tech Company/Witt, Fiala, Flannery .
and Associates, Inc dba WFF Facility Services
801920
RESUMEN DE BENEFICIOS
Planes de seguro voluntarios de Aetna
Los beneficios y el diseño de plan son provistos por Aetna Life Insurance Company (Aetna)
y administrado por Aetna o Strategic Resource Company (SRC).
A menos que se especifíque lo contrario, todos los beneficios y limitaciones aplican a cada persona cubierta.
Dentro de este Resumen de Beneficios:
• Indemnización de hospital y médico
• Indemnización de hospital
• Cuidado de la vista
• Incapacidad a corto plazo (ICP)
INFORMACIÓN IMPORTANTE SOBRE LOS BENEFICIOS QUE SE LE OFRECEN: ¡Guarde este
estado de cuenta! Podría servirle en el futuro. Estos beneficios no constituyen un seguro médico
completo y no cubrirán el costo de la mayoría de servicios hospitalarios y otros servicios
médicos. Este aviso le da una descripción muy breve de las características importantes de los
beneficios considerados. No es un contrato de seguro y son las disposiciones de la póliza en sí las que
prevalecerán. La póliza en sí incluirá detalles sobre los derechos y obligaciones del titular principal de
la póliza y Aetna Life Insurance Company. Estos beneficios se han diseñado de forma que se le pague
un monto fijo en dólares sin importar el monto que cobre el proveedor. Los pagos no se basan en un
porcentaje del cargo del proveedor y se pagan adicionalmente a cualquier otro plan de cobertura
médica que pueda tener.
Aetna pagará beneficios sólo por los gastos incurridos mientras esta cobertura tenga vigencia y sólo para el tratamiento
médicamente necesario para una lesión o enfermedad. Los beneficios mostrados en este Resumen de Beneficios refleja
ciertas disposiciones del estado en el que se escribió la póliza. Sin embargo, ciertas leyes federales u otras disposiciones del
estado en el que vive y/o trabaja también podrían afectar cómo se pagan estos beneficios.
Beneficios de indemnización de hospital y médico: Opción 1
Lo máximo que éste plan pagaría por año de cobertura por:
Visitas al consultorio médico ambulatorio
5 visitas a $55 por visita
Visitas de atención médica preventiva
1 visita a $75 por visita
Servicios diagnósticos ambulatorios
3 días a $65 por día
Sala de emergencia
Ambulancia
3 viajes a $50 por viaje
Cirugía ambulatoria
2 cirugías a $150 por cirugía
Anestesia para pacientes ambulatorios
2 veces a $75 cada vez
Tratamientos relativos a accidentes
2 incidentes a $100 por incidente
Admisión hospitalaria
2 admisiones a $400 por admisión
Hospitalizaciones
Cuarto hospitalario
2 estadías a $250 por día durante 30 días
o Unidad de Cuidados Intensivos
Cirugía con hospitalización
2 cirugías a $150por cirugía
Anestesia con hospitalización
Visitas del médico durante hospitalización
1 visita al día a $25 por visita durante 30 días
Medicamentos bajo receta
12 recetas médicas a $20 por receta médica
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Resumen de beneficios
Página 1
801920
Beneficios de indemnización de hospital y médico: Opción 2
Lo máximo que éste plan pagaría por año de cobertura por:
1 visita a $100 por visita
4 días a $80 por día
Sala de emergencia
Ambulancia
3 viajes a $100 por viaje
Anestesia para pacientes ambulatorios
Tratamientos relativos a accidentes
2 incidentes a $150 por incidente
2 admisiones a $600 por admisión
Hospitalizaciones
Cuarto hospitalario
o Unidad de Cuidados Intensivos
1 visita al día a $25 por visita durante 30 días
Medicamentos bajo receta
12 recetas médicas a $25 por receta médica
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801920
Esta póliza no cumple con las normas de cobertura comprobable mínima de Massachusetts.
Indemnización de hospital y médico: Opción 1
El cargo del proveedor puede ser más bajo si usa un proveedor preferido que pertenece a la red de Aetna (de
acuerdo con el proveedor y ubicación). Para ubicar a un proveedor preferido, llame al número de teléfono sin cargo
1-888-772-9682 o visite el sitio de Internet www.aetna.com/docfind/custom/avp.
Incluye el servicio de los médicos en el consultorio, domicilio, sala de emergencias y clínica de atención sin citas. (También
incluye el tratamiento en caso de accidentes después de 72 horas).
Número máximo de visitas por año de cobertura (incluye la atención médica de
rutina hasta los 6 años)
Pago del plan por visita
5 visitas
$55
Número máximo de visitas por año de cobertura
1 visita
$75
Excluye análisis en el consultorio de los médicos que se consideran parte del cargo de la visita al consultorio.
Número máximo de días por año de cobertura
Pago del plan por día
3 días
$65
Sala de emergencia
3 visitas
$100
Ambulancia
Número máximo de viajes por año de cobertura
Pago del plan por viaje
3 viajes
$50
Número máximo de cirugías por año de cobertura
2 cirugías
Pago del plan por cirugía
$150
Número máximo de inducciones de anestesia por año de cobertura
2 veces
Pago del plan por inducción de anestesia
$75
Tratamiento en relación a accidentes
En el plazo de 72 horas, incluye:
Número máximo de incidentes por año de cobertura
2 incidentes
Pago del plan por incidente
$100
Número máximo de admisiones hospitalarias por año de cobertura
2 admisiones
Pago del plan por admisión
$400
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801920
Hospitalizaciones
(incluye maternidad)
Número máximo de hospitalizaciones por año de cobertura
2 estadías hospitalarias
Número máximo de días por hospitalización
30 días
Pago del plan por día en una habitación privada o semiprivada
$250
Pago del plan por día en la Unidad de Cuidados Intensivos (UCI)
$500
2 cirugías
$150
2 veces
$75
Número máximo de visitas por día
1 visita
$25
30 días
Cargos por medicamentos bajo receta
Número máximo de recetas médicas por año de cobertura
12 recetas médicas
Pago del plan por cada receta médica
$20
Para usar su beneficio de farmacia:
A) Presente su tarjeta de identificación de Aetna al farmacéuta.
B) Las farmacias que pertenecen a la red aplicarán un descuento.
C) Usted paga el monto que cobra la farmacia.*
D) Presente un formulario de reclamo médico a SRC para recibir el reembolso correspondiente.*
* Si la farmacia presenta su(s) reclamo(s) en su nombre, no tendrá que seguir estos pasos.
Sólo se cubre recetas médicas, a excepción de las recetas dentales emitidas en relación al tratamiento de un accidente
cubierto.
Para encontrar una farmacia preferida, llame sin cargo al 1-888-772-9682 o visite el sitio de Internet
Aviso sobre la Parte D de Medicare: Este beneficio de farmacia no reúne los criterios de la cobertura de la Parte D de
Medicare; no llega a ser equivalente al plan ofrecido bajo la Parte D de Medicare.
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Indemnización de hospital y médico: Opción 2
El cargo del proveedor puede ser más bajo si usa un proveedor preferido que pertenece a la red de Aetna (de
acuerdo con el proveedor y ubicación). Para ubicar a un proveedor preferido, llame al número de teléfono sin cargo
1-888-772-9682 o visite el sitio de Internet www.aetna.com/docfind/custom/avp.
Incluye el servicio de los médicos en el consultorio, domicilio, sala de emergencias y clínica de atención sin citas. (También
incluye el tratamiento en caso de accidentes después de 72 horas).
Número máximo de visitas por año de cobertura (incluye la atención médica de
rutina hasta los 6 años)
7 visitas
$65
1 visita
$100
Excluye análisis en el consultorio de los médicos que se consideran parte del cargo de la visita al consultorio.
Pago del plan por día
4 días
$80
Sala de emergencia
3 visitas
$200
Ambulancia
Número máximo de viajes por año de cobertura
Pago del plan por viaje
3 viajes
$100
2 cirugías
$250
2 veces
$125
Tratamiento en relación a accidentes
En el plazo de 72 horas, incluye:
Número máximo de incidentes por año de cobertura
2 incidentes
Pago del plan por incidente
$150
Número máximo de admisiones hospitalarias por año de cobertura
2 admisiones
Pago del plan por admisión
$600
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Hospitalizaciones
(incluye maternidad)
Número máximo de hospitalizaciones por año de cobertura
2 estadías hospitalarias
Número máximo de días por hospitalización
30 días
Pago del plan por día en una habitación privada o semiprivada
$400
Pago del plan por día en la Unidad de Cuidados Intensivos (UCI)
$800
2 cirugías
$250
2 veces
$125
Número máximo de visitas por día
1 visita
$25
30 días
Cargos por medicamentos bajo receta
Número máximo de recetas médicas por año de cobertura
12 recetas médicas
Pago del plan por cada receta médica
$25
Para usar su beneficio de farmacia:
A) Presente su tarjeta de identificación de Aetna al farmacéuta.
B) Las farmacias que pertenecen a la red aplicarán un descuento.
C) Usted paga el monto que cobra la farmacia.*
D) Presente un formulario de reclamo médico a SRC para recibir el reembolso correspondiente.*
* Si la farmacia presenta su(s) reclamo(s) en su nombre, no tendrá que seguir estos pasos.
Sólo se cubre recetas médicas, a excepción de las recetas dentales emitidas en relación al tratamiento de un accidente
cubierto.
Para encontrar una farmacia preferida, llame sin cargo al 1-888-772-9682 o visite el sitio de Internet
Aviso sobre la Parte D de Medicare: Este beneficio de farmacia no reúne los criterios de la cobertura de la Parte D de
Medicare; no llega a ser equivalente al plan ofrecido bajo la Parte D de Medicare.
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Cuando se inscribe en beneficios de indemnización de hospital y médico, también recibirá:
Descuentos* para la vista de Aetna Vision SM
Descuentos para la vista de Aetna Vision SM , utiliza la red nacional de EyeMed Select de proveedores de la vista que le ofrece
a usted y a su familia lentes, lentes de contacto, lentes de sol sin medida, soluciones para lentes de contacto y otros
accesorios para el cuidado de la vista a precios descontados. Asimismo, puede recibir descuentos en exámenes de la vista y
cirugía de los ojos LASIK. Para exámenes de la vista y lentes, llame al número 1-800-793-8616. Para lentes de contacto,
llame al 1-800-391-5367. Para servicio al cliente de LASIK, llame al 1-800-422-6600. También puede ubicar un proveedor
local visitando el sitio de Internet www.aetna.com/docfind/custom/avp. Este arreglo de descuento puede no estar
disponible en Illinois.
Programa de descuento de farmacia*
El programa de descuento de farmacia le da a usted y a su familia acceso a más de 59,000 farmacias a nivel nacional,
incluyendo las cadenas de farmacias principales y farmacias independientes (Base de datos de farmacia de la red de Aetna,
20 de marzo de 2008). Para ubicar una farmacia que pertenece a la red, llame al 1-888-772-9682 o visite el sitio de Internet
*Los programas de descuento proporcionan acceso a tarifas reducidas y no son beneficios asegurados.
Informed Health ® Line (Línea informativa de la salud)
La Línea informativa de la salud de Aetna le da a usted y a su familia acceso a enfermeros registrados las 24 horas del día,
los 7 días de la semana. Este número de teléfono sin cargo le comunica con un equipo de enfermeros con experiencia en
proporcionar información sobre una variedad de temas médicos. Los enfermeros de la Línea informativa de la salud usan
Healthwise ® Knowledgebase procedimientos médicos y opciones de tratamientos y le ayudan a usted y a su familia a
comunicarse más eficazmente con sus médicos. También puede optar por oír ciertos temas sobre la salud de su interés a
través de la biblioteca médica de audio de Aetna, que está disponible en inglés y español. Llame a la Línea informativa de la
salud de Aetna al número 1-800-556-1555.
Programa de asistencia al empleado
El programa de asistencia al empleado de Aetna le ayuda a usted y a su familia a manejar el estrés y equilibrar el trabajo y la
vida. Recursos relacionados con el apoyo emocional, cuidado de niños, orientación legal y financiera están disponibles por
teléfono y por el Internet.
Los servicios también incluyen consulta, información, educación y servicios de referencia en relación con:
• crianza de los hijos
• adopción
• abuelos como padres
• cuidado de niños y cuidado durante el verano
• respaldo temporal de cuidado
• necesidades especiales
• adolescentes de alto riesgo
• salud mental
• servicios académicos
• cuidado de adultos y cuidado de personas de la tercera edad
• mejoras para el hogar
• cuidado de mascotas
• información para el consumidor
• servicios legales
• asesoría financiera
• información de seguridad para niños
• información prenatal
Estos servicios son convenientes y confidenciales, disponible las 24 horas al día, 7 días a la semana, llamando al 1-888AETNA-EAP (1-888-238-6232) o visitando el sitio de Internet www.AetnaEAP.com.
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Exclusiones y limitaciones del plan de indemnización de hospital y médico
Este plan no cubre todos los gastos médicos y tiene exclusiones y limitaciones. Los miembros deben consultar su folleto
certificado para determinar qué servicios médicos están cubiertos y hasta qué punto. Ésta es una lista parcial de los
servicios y suministros que generalmente no están cubiertos . Sin embargo, su plan puede contener excepciones a esta
lista de acuerdo con los mandatos estatales o con el diseño del plan comprado.
Exclusiones del plan de indemnización de hospital y médico:
• Todos los servicios médicos u hospitalarios no cubiertos específicamente en los documentos del plan o que están limitados
o excluidos de los mismos;
• Cirugía cosmética, incluyendo la reducción de senos;
• Cuidado de custodia.
• Obtención de óvulos de donantes;
• Procedimientos experimentales y de investigación;
• Servicios de infertilidad, incluyendo, sin limitaciones, la inseminación articifial y las tecnologías reproductivas avanzadas;
• Servicios o suministros que no son médicamente necesarios;
• Inversión de la esterilización
No se paga ningún beneficio relacionado con las siguientes hospitalizaciones, visitas o servicios.
• Los que se reciben fuera de los Estados Unidos
• Aquellos para la educación, educación especial o instrucción ocupacionas ya sea que sea impartida o no en un centro que
también proporciona tratamiento médico o psiquiátrico.
Definición de términos
Un servicio o suministro es médicamente necesario si Aetna determina que es apropiado para el diagnóstico, atención
médica o tratamiento de la enfermedad o lesión del caso. Vea los documentos del plan para obtener una definición completa
Los cargos por hospitalización son todos los cargos en los que incurre al hospitalizarse en un hospital u otro centro de
hospitalización.
Los cargos ambulatorios son los cargos por los servicios y suministros proporcionados en el consultorio médico, clínicas
independientes y centros de hospitalización. También incluye los cargos en hospitales cuando usted no es hospitalizado,
incluyendo los cargos de la sala de emergencia.
Un cargo negociado es el monto máximo que un proveedor preferido ha acordado cobrar por una visita, servicio o
suministro cubierto. Después de llegar a los límites de su plan, el proveedor puede requerir que usted pague el cargo
completo en lugar del cargo negociado.
Las visitas de atención preventiva son las visitas al médico para obtener servicios que no tengan el fin de diagnosticar ni
tratar una lesión o enfermedad. Algunos tipos comunes de visitas de atención preventiva son los exámenes físicos anuales,
exámenes ginecológicos, visitas pediátricas de rutina, mamografías, algunas pruebas de detección de cáncer y medidas de la
densidad de la masa ósea. Las radiografías, análisis de laboratorio y otros exámenes, así como materiales para la
administración de inmunizaciones y examen de tuberculosis están incluidos como parte de la visita de atención preventiva.
Su plan probablemente no ofrezca un beneficio de visitas de atención preventiva. Por favor consulte el cuadro de beneficios
de este Resumen de Beneficios. Algunas leyes federales y estatales disponen ciertos exámenes preventivos que deben ser
cubiertos por este beneficio u otorgados adicionalmente a ellos si su plan lo ofrece. Si el plan no ofrece un beneficio de visita
de atención preventiva (vea el cuadro de beneficios), estas disposiciones serán cubiertas por otros beneficios de su plan. Por
favor consulte los documentos de su plan para obtener más información.
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Otra cobertura disponible:
Indemnización de hospital
Beneficio de suma global
$1,000 por un confinamiento en el hospital como paciente internado por año
de cobertura; y
Beneficio diario
$100 al día de hasta 100 días de confinamiento en el hospital como paciente
internado por año de cobertura.
Se aplica este beneficio si usted o un dependiente con cobertura está confinado en un hospital como paciente internado.
Exclusiones y limitaciones del plan de indemnización de hospital:
certificado para determinar qué servicios médicos están cubiertos y hasta qué punto. Las mismas limitaciones y exclusiones,
como las enumeradas, corresponden a la cobertura del plan de indemnización de hospital y médico y/o dental (si se ofrece
por el plan). Sin embargo, su plan puede contener excepciones a esta lista de acuerdo con los mandatos estatales o
con el diseño del plan comprado.
Cuidado de la vista
Exámenes de la vista
Reembolso de hasta $100 cada 12 meses por un examen, monturas, lentes
o lentes de contacto.
Los beneficios y descuentos se aplican a cada persona con cobertura. Las tarifas de otros servicios deberán ser pagadas por
usted. El período de beneficios consiste en 12 meses consecutivos desde la fecha de vigencia o su examen de la vista más
reciente cubierto por este plan.
Cuando se inscribe en la cobertura para el cuidado de la vista, también recibirá:
Descuentos* para la vista de Aetna
Vision SM
Descuentos para la vista de Aetna Vision SM , utiliza la red nacional de
EyeMed Select de proveedores de la vista que le ofrece a usted y a su
familia lentes, lentes de contacto, lentes de sol sin medida, soluciones para
lentes de contacto y otros accesorios para el cuidado de la vista a precios
descontados. Asimismo, puede recibir descuentos en exámenes de la vista y
cirugía de los ojos LASIK. Para exámenes de la vista y lentes, llame al
número 1-800-793-8616. Para lentes de contacto, llame al 1-800-391-5367.
Para servicio al cliente de LASIK, llame al 1-800-422-6600. También puede
ubicar un proveedor local visitando el sitio de Internet
*Los programas de descuento proporcionan acceso a tarifas reducidas y no son beneficios asegurados. Este arreglo de
descuento puede no estar disponible en Illinois.
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Exclusiones del cuidado de la vista:
certificado para determinar qué servicios médicos están cubiertos y hasta qué punto. Ésta es una lista parcial de los
servicios y suministros que generalmente no están cubiertos . Sin embargo, su plan puede contener excepciones a esta
lista de acuerdo con los mandatos estatales o con el diseño del plan comprado.
• Formación ortóptica para la vista, ayudas para la vista subnormales, cualquier prueba complementaria asociada.
• Tratamiento médico o quirúrgico de los ojos o soporte de estructuras.
• Cualquier examen ocular o de la vista, o cualquier lente correctivo para la vista, requerido por un empleador como condición
del empleo.
Seguro de incapacidad a corto plazo
Período de beneficios
Beneficios semanales hasta por 6 meses mientras está incapacitado.
Monto del beneficio
50% del pago básico recibido del empleador que patrocina este programa
(incluye las propinas declaradas, pero no el sobretiempo) hasta un beneficio
máximo de $125 semanales.
Período de espera
Los beneficios comienzan después de 14 días (el plan paga inmediatamente
si está hospitalizado).
Cobertura sólo para el empleado; cobertura no disponible en California, Hawaii, New Jersey, New York, Rhode Island y Puerto
Rico.
Exclusiones del seguro de incapacidad a corto plazo:
Este plan no cubre todas las circunstancias y tiene exclusiones y limitaciones. Los miembros deben consultar su folleto
certificado para determinar qué circunstancias están cubiertas y hasta qué punto. Ésta es una lista parcial de las
circunstancias que generalmente no están cubiertas. Sin embargo, su plan puede contener excepciones a esta lista de
acuerdo con los mandatos estatales o con el diseño del plan comprado.
• Intento de suicidio, si está cuerdo o no, o una lesión o enfermedad autoinflijida intencionadamente, a menos que sea
originada por una condición médica.
• Comisión o intención de cometer un acto que se considera delito en la jurisdicción en que ocurrió el acto.
• Abuso de substancias.
• Enfermedades o lesiones ocupacionales.
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Preguntas y respuestas sobre la indemnización de hospital y médico, o indemnización de hospital (si se
ofrece)
Si se ofrece, los planes de indemnización de hospital y médico, o indemnización de hospital, son planes de
indemnización fija. ¿Cómo funcionan los planes de indemnización fija?
Los planes de indemnización fija no tienen copagos, deducibles ni coseguro. Un plan de indemnización fija paga un monto
fijo por servicio, con límites en el número y en los tipos de servicios. Una vez que ha usado el número de servicios asignado,
el plan ya no pagará por ese tipo de servicio. Debido a que el plan paga una cantidad fija, usted podría deberle al proveedor
más de lo que el plan paga. Si opta por un proveedor preferido (que pertenece a la red), podría tener que pagar menos
porque el proveedor puede aceptar pago por el cargo negociado. Antes de inscribirse en el plan, por favor lea el cuadro de
beneficios de las páginas anteriores detenidamente para entender lo que pagará este plan.
¿En qué se diferencia el plan de indemnización fija del plan médico mayor tradicional?
Hay diferencias importantes en el monto que el plan pagará y el costo de las primas. Ambos tipos de planes pagan beneficios
por muchos tipos de servicios y suministros. Sin embargo, este plan de seguro de indemnización fija paga un monto fijo por
tipo de servicio y coloca límites sobre las veces que pagará por cada categoría de servicio o suministro. Una vez que haya
agotado los límites de un beneficio específico, el plan no pagará más por él. A diferencia de la mayoría de planes médicos
mayores, este plan de seguro de indemnización fija no tiene cobertura catastrófica ni un límite sobre sus gastos de bolsillo.
Esto significa que podría tener costos de bolsillo importantes si tiene una condición médica grave o crónica. Como los planes
médicos mayores tradicionales proporcionan más cobertura, cuestan más.
¿Como se diferencia un plan de indemnización fija de un plan de beneficios limitados?
Si anteriormente estuvo inscrito en un plan de seguro de beneficios limitados, es importante entender cómo se diferencia el
plan de indemnización fija. Un plan de beneficios limitado, paga un porcentaje del cargo (coseguro) hasta por un monto
máximo y ocasionalmente puede tener límites en el número de servicios. Un plan de indemnización fija paga un monto fijo
por servicio sin importar la cantidad del cargo, con límites sobre el número de algunos servicios. Un plan de beneficios
limitado puede tener copagos y deducibles. Los planes de indemnización fija no tienen copagos, deducibles ni coseguro.
¿El plan de indemnización fija proporciona cobertura comprobable o la continuación de cobertura de COBRA?
A diferencia del plan médico mayor tradicional o el plan de beneficios limitados Aetna, este plan de indemnización fija no
proporciona cobertura comprobable de acuerdo con HIPAA y no ofrece la continuación de cobertura de COBRA.
¿Cuánto pagaré por adelantado cuando voy a un proveedor médico?
Un proveedor puede exigir que usted pague todos los cargos por adelantado, y sería su decisión presentar un reclamo de
reembolso por cualquier cargo que el plan pueda pagar.
¿Qué debo hacer si no comprendo algo de lo que leí aquí, o tengo dudas?
Por favor, llámenos. Queremos que usted comprenda estos beneficios antes de decidir inscribirse. Puede comunicarse con
uno de nuestros representantes de Servicio al Cliente de lunes a viernes, de 8 a.m. a 8 p.m., hora del Este, al número de
teléfono sin cargo 1-888-772-9682. Estamos disponibles para responder sus preguntas antes y después de su inscripción.
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ESTE PLAN NO OFRECE COBERTURA MÉDICA COMPLETA. ES UNA PÓLIZA DE
INDEMNIZACIÓN Y NO TIENE EL PROPÓSITO DE CUBRIR TODOS LOS GASTOS MÉDICOS.
ESTE PLAN NO HA SIDO DISEÑADO PARA CUBRIR LOS COSTOS DE ENFERMEDADES GRAVES
O CRÓNICAS. CONTIENE LÍMITES ESPECÍFICOS QUE SE PAGARÁN POR SERVICIOS MÉDICOS,
QUE NO PUEDE SER EXCEDIDO. SI EL COSTO DE SERVICIOS SUPERA DICHOS LÍMITES, EL
BENEFICIARIO, Y NO EL ASEGURADOR, SERÁ RESPONSABLE DEL PAGO DEL MONTO EN
EXCESO. LOS LÍMITES ESPECÍFICOS ESTÁN DESCRITOS EN ÉSTE RESUMEN DE BENEFICIOS.
ATENCIÓN RESIDENTES DE MASSACHUSETTS: A partir del 1 de enero de 2009, la Ley de Reforma de la Atención
Médica de Massachusetts requiere que los residentes de Massachusetts de dieciocho (18) años o más, deben tener una
cobertura médica que reúna las normas de cobertura comprobable mínima definidas por el Conector de Seguro Médico del
Commonwealth, a menos que sea exonerado del requisito de seguro médico de acuerdo con asequibilidad económica o
indigencia. Para obtener más información, llame al Conector al 1-877-MA-ENROLL (1-877-623-6765) o visite el sitio de
Internet del Conector en (www.mahealthconnector.org). ESTA PÓLIZA, EN SÍ, NO REÚNE LAS NORMAS DE COBERTURA
COMPROBABLE MÍNIMA. Si tiene preguntas sobre este aviso, puede comunicarse con la División de Seguros al número
617-521-7794 o a través del sitio de Internet www.mass.gov/doi.
Este material tiene sólo fines informativos y no constituye un contrato. Los planes de seguro contienen exclusiones y
limitaciones. Los proveedores son contratistas independientes y no son agentes de Aetna. La participación de un proveedor
puede cambiar sin aviso. Aetna no proporciona atención médica y por lo tanto no puede garantizar acceso a servicios
médicos. No todos los servicios médicos están cubiertos. Consulte los documentos del plan para obtener una descripción
completa de los beneficios, limitaciones y condiciones de cobertura. Las características del plan y disponibilidad pueden
variar por ubicación. Aetna recibe descuentos de los fabricantes de medicamentos que se pueden tomar en cuenta al
determinar el Listado de medicamentos preferidos de Aetna. Los descuentos no reducen la cantidad que el miembro paga
por medicamentos cubiertos en la farmacia. Los programas de descuento proporcionan acceso a tarifas descontadas y no
son beneficios asegurados. Si bien se cree que la información dada en el presente documento es precisa a la fecha de
producción; está sujeta a cambios.
Los planes de seguro están suscritos por Aetna Life Insurance Company (conocido como "Aetna") y administrado
por Aetna o Strategic Resource Company (SRC, una compañía de Aetna).
Para los residentes de OK, los formularios de póliza emitidos incluyen GR-9/GR-9N, GR-29/GR-29N, GR96172, y GR96173.
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Associates, Inc. dba WFF Facility Services
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Planes voluntarios de Aetna
(anteriormente Aetna Affordable Health Choices®)
Solicitud de Inscripción o Cambio
Los planes de seguro están suscritos por Aetna Life Insurance Company (conocido como "Aetna") y
administrado por Aetna o Strategic Resource Company (SRC, una compañía de Aetna)
Instrucciones: Lea y complete esta Solicitud de Inscripción o Cambio (todas las páginas). Haga una copia para usted. Dé el original a su empleador.
INFORMACIÓN SOBRE USTED Llene toda la información.
Escriba su nombre en letra de imprenta (nombre, inicial del segundo nombre, apellido)
Dirección residencial
Número de apartamento
Número de teléfono de casa
Número de teléfono del trabajo
Número de Seguro Social
Ciudad
Dirección de e-mail
(
)
(
)
ACCIÓN QUE DESEA TOMAR Marque la casilla de al lado de la acción que desea tomar.
Fecha de nacimiento (MM/DD/AAAA)
Estado
Sexo  Masculino
 Femenino
Código postal
Idioma principal
No estoy actualmente inscrito y deseo…
 Inscribirme en las coberturas seleccionadas abajo.
 Declinar esta oportunidad de participar.
Estoy actualmente inscrito y deseo…
 Cambiar mis selecciones de cobertura actual (agregar, aumentar, cancelar, reducir) según las selecciones de abajo.
Todas mis otras opciones de cobertura permanecerán igual que antes. (Si está fuera del período de inscripción abierta, vea
“Cambios fuera del período de inscripción abierta.”)
 Poner al día mi información personal, de dependiente.
 Cancelar mi opción de cobertura actual.
Sus deducciones salariales serán descontadas antes de impuestos. (Las deducciones de Incapacidad a corto plazo y de Seguro de vida a plazo fijo se harán después de
impuestos.)
SUS OPCIONES DE COBERTURA Marque () la casilla para el nivel de cobertura que desea.
Tipo de cobertura
Nivel de cobertura
Costo semanal
Indemnización de hospital y
médico
Solo puede inscribirse en una
opción médica.
 No a la Indemnización de hospital y médico
Opción 1
 Sólo usted............................................................................................................................................................................$
 Usted más uno.....................................................................................................................................................................$
 Usted y familia .....................................................................................................................................................................$
Opción 2
 Sólo usted............................................................................................................................................................................$
 Usted más uno.....................................................................................................................................................................$
 Usted y familia .....................................................................................................................................................................$
18.78
46.95
65.73
3.80
7.60
11.40
Indemnización de hospital




No a la Indemnización de hospital
Sólo usted............................................................................................................................................................................$ 3.80
Usted más uno.....................................................................................................................................................................$ 7.60
Usted y familia .....................................................................................................................................................................$ 11.40
Cuidado de la vista




No al Cuidado de la vista
Sólo usted............................................................................................................................................................................$
Usted más uno.....................................................................................................................................................................$
Usted y familia .....................................................................................................................................................................$
1.00
1.70
2.40
Incapacidad a corto plazo
SU AUTORIZACIÓN
 No a la Incapacidad a corto plazo
 Sólo usted............................................................................................................................................................................$ 3.50
La cobertura no está disponible si trabaja en California, Hawaii, New Jersey, New York, Rhode Island y Puerto Rico.
Debe firmar y fechar esta Solicitud de Inscripción o Cambio para todos los cambios nuevos de inscripción o cobertura.
Represento que toda la información suministrada en ésta Solicitud de Inscripción o Cambio es verdadera y completa según mi mejor saber y entender. He leído y estoy de
acuerdo con las Condiciones de Inscripción de la parte de atrás de ésta Solicitud de Inscripción o Cambio.
Su firma
Fecha de hoy (MM/DD/AAAA)
INFORMACIÓN DE GRUPO DEL EMPLEADOR Esta sección debe llenarla el empleador.
Identificación de empleado
Fecha de contratación
(MM/DD/AAAA)
Código del centro o ubicación
Firma autorizada
Tipo de pago
Deducción total ($)
Fecha de vigencia (MM/DD/AAAA)
Puesto
Fecha de hoy (MM/DD/AAAA)
Esta Solicitud de Inscripción o Cambio no constituye una prueba de cobertura.
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INFORMACIÓN SOBRE USTED Repita su nombre y número de Seguro Social aquí.
Escriba su nombre en letra de imprenta (nombre, inicial del segundo nombre, apellido)
INFORMACIÓN PARA SUS DEPENDIENTES Indique los dependientes cuya cobertura está agregando, cambiando o retirando.
Si tiene más dependientes, escriba la información correspondiente en una hoja suelta y adjúntela a esta Solicitud de Inscripción o Cambio.
 Agregar
Escriba en letra de imprenta el nombre del dependiente (nombre, inicial del segundo nombre, apellido)
 Cambiar
 Retirar
Sexo
Fecha de nacimiento
Inscrito en:  Indemnización de hospital y médico /  Indemnización de hospital /
 Masculino /  Femenino
 Cuidado de la vista
Parentesco:
 Cónyuge
 Hijo
Dirección (si difiere de la suya)
 Agregar
 Cambiar
 Retirar
 Otro (Especifique): ___________________________________________
Ciudad
Estado
Sexo
Fecha de nacimiento
Código postal
Parentesco:
 Cónyuge
 Hijo
 Agregar
 Cambiar
 Retirar
Ciudad
Estado
Sexo
Fecha de nacimiento
Código postal
Parentesco:
 Cónyuge
 Hijo
Ciudad
Estado
Código postal
CAMBIOS FUERA DEL PERÍODO DE INSCRIPCIÓN ABIERTA Por favor lea abajo para ver si puede cambiar su cobertura.
Si sus deducciones se hacen antes de la deducción de impuestos sobre sus ingresos puede
cambiar su cobertura durante el año del plan solo si tiene un Evento de Vida Permisible. Si
sus deducciones se hacen después de la deducción de impuestos, puede cancelar o reducir su
cobertura en cualquier momento. Los Eventos de Vida Permisibles corresponden a una de
estas dos categorías:
Pérdida de Otra Cobertura (POC): Si usted previamente declinó cobertura médica debido a
que usted o sus dependientes contaban con cobertura bajo otro plan médico y han perdido esa
cobertura, es posible que usted y sus dependientes puedan inscribirse. Si ha tenido una
pérdida de otra cobertura reciente, vea la lista de la derecha y marque la casilla de al lado de
su POC e indique la fecha de la POC.
Cambios en Estado Familiar (CEF): Si actualmente está inscrito o previamente declinó
cobertura, es posible que pueda agregar o aumentar, cancelar o reducir su cobertura cuando
experimente ciertos eventos de CEF. Si ha tenido un cambio en estado familiar reciente, vaya
a la lista de la derecha y marque la casilla de al lado de su CEF e indique la fecha del CEF.
Luego, complete el resto de esta Solicitud de Inscripción o Cambio. Al terminar, haga una
copia y entréguesela a su empleador con la documentación adjunta. Debe entregar esta
Solicitud de Inscripción o Cambio, junto con la documentación correspondiente a su empleador
en el plazo de 30 días de la POC/CEF.
Pérdida de Otra Cobertura (POC):
 Divorcio, separación legal o muerte
 Cese de empleo de su dependiente
 Reducción de las horas de trabajo de su dependiente
 Terminación de los derechos de COBRA de usted o sus
dependientes
 Pérdida de la contribución del empleador a la cobertura de su
cónyuge
 Pérdida de la elegibilidad como dependiente de su dependiente
 Otra pérdida de cobertura
Cambios en Estado Familiar (CEF):
 Divorcio, separación legal o muerte
 Matrimonio
 Nacimiento o adopción de un dependiente
 Otro
Fecha de la POC o del CEF (mm/dd/aaaa)
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CONDICIONES DE INSCRIPCIÓN Reconocimientos y declaraciones del solicitante
En mi nombre y en nombre de los dependientes enumerados en esta Solicitud de Inscripción o Cambio, estoy de acuerdo con lo siguiente:
1. Reconozco que al inscribirme en un plan de Aetna, la cobertura es suscrita o administrada por Aetna Life Insurance Company (en adelante, "Aetna") 151 Farmington
Avenue, Hartford, CT 06156 y administrado por Aetna o Strategic Resource Company (SRC, una compañía de Aetna), 221 Dawson Road, Columbia, SC 29223.
2. Autorizo que se efectúe deducciones de mis ingresos para el pago de las contribuciones necesarias para recibir cobertura y estoy de acuerdo con hacer todos los
pagos necesarios para recibir cobertura.
3. Entiendo y estoy de acuerdo con que esta Solicitud de Inscripción o Cambio puede ser transmitida a Aetna o su apoderado por mi empleador o su apoderado.
Autorizo a cualquier médico, otro profesional de la salud, hospital o cualquier otra organización médica ("Proveedores") a suministrar a Aetna o su apoderado
información relativa a la historia, servicios o tratamientos médicos provistos a cualquiera de las personas enumeradas en esta Solicitud de Inscripción o Cambio,
incluyendo aquellos relativos a la salud mental, abuso de sustancias tóxicas y VIH o SIDA. Asimismo, autorizo a Aetna a utilizar dicha información y divulgarla a sus
afiliados, proveedores, pagadores, otros aseguradores, administradores externos, distribuidores, consultores y autoridades gubernamentales con jurisdicción cuando
sea necesario para mi cuidado o tratamiento, el pago por servicios, la operación de mi plan médico o para llevar a cabo actividades relacionadas. He hablado de los
términos de esta autorización con mi cónyuge y dependientes mayores de edad competentes y he obtenido su consentimiento a dichos términos. Entiendo que esta
autorización ha sido provista de acuerdo con las leyes del estado y que no corresponde a la "autorización" como se entiende de acuerdo con la Ley Federal de
Portabilidad y Responsabilidad de Seguros Médicos. Esta autorización será válida durante el término de la cobertura y posteriormente siempre y cuando la ley lo
permita. Entiendo que tengo derecho a recibir una copia de esta autorización a solicitud y que una fotocopia será tan válida como el documento original.
4. Los documentos del plan determinarán los derechos y responsabilidades de los miembros y regirán en caso de conflicto con cualquier comparación o resumen de
beneficios, o con cualquier otra descripción del plan.
5. Entiendo y estoy de acuerdo con que, a excepción del servicio de entrega de medicamentos a domicilio Aetna Rx Home Delivery®, todos los proveedores y
distribuidores que pertenecen a la red son contratistas independientes y no son ni agentes ni empleados de Aetna. Aetna Rx Home Delivery, LLC, es una
subsidiaria de Aetna Inc. La disponibilidad de cualquier proveedor en particular no puede ser garantizada y la composición de la red de proveedores está sujeta a
cambios. Dichos cambios serán notificados de acuerdo con la ley estatal aplicable.
6. Información falsa:
Cualquier persona que, a sabiendas y con la intención de perjudicar, defraudar o engañar a cualquier compañía de seguros u a otra persona, presente una solicitud
de seguro o declaración de reclamo que contiene información materialmente falsa u oculta información, con el fin de engaño, relativa a cualquier hecho material del
reclamo, habrá cometido un acto fraudulento de seguro, lo que es considerado un delito, y por lo tanto, dicha persona quedará sujeta a las sanciones penales o
civiles correspondientes.
Atención residentes de Pennsylvania: Cualquier persona que, a sabiendas y con la intención de perjudicar, defraudar o engañar a cualquier compañía de seguros
u a otra persona, presente una solicitud de seguro o declaración de reclamo que contiene información materialmente falsa u oculta información, con el fin de
engaño, relativa a cualquier hecho material del reclamo, habrá cometido un acto fraudulento de seguro, lo que es considerado un delito, y por lo tanto, dicha persona
quedará sujeta a las sanciones penales o civiles correspondientes.
Atención residentes de Rhode Island: Cualquier persona que, a sabiendas, presente un reclamo falso o fraudulento para el pago de un siniestro o beneficio, o, a
sabiendas, presente información falsa en una solicitud de seguro, es culpable de un delito y puede estar sujeto a multas y encarcelamiento.
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