Managed Benefits Program

This Program has been designed to encourage the efficient and effective use of hospital and medical services by providing you with medical and financial information before the services are provided. The benefits provided by your Plan are limited to charges for services which are medically necessary and appropriate for the care and treatment of an illness or injury. As such, charges are covered only if they are necessary for the care and treatment of a covered illness or injury. This includes the type of service and length of confinement, if applicable.

Please refer to Appendix A for additional information about Utilization Review and your right to appeal negative decisions made regarding the medical necessity or experimental/ investigative aspect of services, treatment or supplies.

ADMISSION AND REVIEW PROGRAM

Elective Admission to a Hospital or Skilled Nursing Facility: At least five working days prior to a scheduled non-emergency, elective in-patient hospitalization or admission to a Skilled Nursing Facility. Most psychiatric and chemical dependence admissions are planned and therefore require authorization at least five days prior to the admission.

Emergency Hospital Admission: Within 48 hours of an emergency or maternity hospitalization.

Home Health Care Services, Private Duty Nursing or Hospice Care: At least five working days prior to commencement of Home Health Care services, Private Duty Nursing or Hospice care.

Elective admission to a facility specializing in psychiatric, mental/nervous conditions or substance abuse, as an inpatient or patient in an intensive outpatient day therapy program:

At least five working days prior to a scheduled admission.

AETNA must be notified in a timely manner about the above services for you to receive the full benefits your health care plan offers. It is the patient’s responsibility to notify Aetna if the provider does not participate in Aetna's Open Choice PPO.

Aetna
1(877) 223-1685

Failure to use the Program as specified above will result in the application of a separate deductible (equal to 50% of benefit otherwise payable up to a maximum of $250), per admission, being applied to any service for which pre-certification is required. Additionally, the member failing to use the Program may assume the risk of liability for services later deemed to be medically unnecessary or available from another primary plan.

CONCURRENT REVIEW PROGRAM
The Concurrent Review Program is initiated when the Admission and Review Program is used. The Program will monitor the hospital or skilled nursing facility stay or Home Health Care or Private Duty Nursing services to determine the continued medical necessity of the treatment plan. If confined for days for which the Concurrent Review Program determines that no medical necessity exists, the Plan may consider the expenses incurred during such days not to be covered expenses.

What happens when you call?

As soon as you are aware of a recommended hospitalization or out-patient treatment, you should call AETNA. When you call, please have the following information available:

• Your name, address and Social Security number.
• Patient’s name, address, Social Security number and age.
• Physician's name, address and phone number. Admitting hospital name and phone number, if appropriate.
• Employees name and Claim Administrator's name.
• Medical condition and planned procedure, if known.

Upon contact, AETNA will provide you with a unique case number to identify and verify your compliance with the Managed Benefits Program requirements.

AETNA will contact the hospital and physician to obtain necessary medical information to evaluate the admission and the treatment plan. AETNA may require that you obtain a second opinion before having an in-patient or out-patient surgical procedure. Regardless of the second opinion recommendation, the decision concerning the surgery is yours.

You will receive information about the proposed treatment including alternative treatments. When unnecessary or inappropriate care is identified, the AETNA Medical Director will discuss the case with your attending physician. Upon completion of the review process, AETNA will advise you, in writing, of its recommendations.

If the admitting doctor determines that you or a covered individual needs to be confined for a longer period than for which benefits were initially authorized by AETNA, the doctor must request authorization from AETNA by phone for the additional period of confinement.
If you or your physician disagree with the recommendation, an appeal process gives you the opportunity to have your case reconsidered. When a request for reconsideration is made, AETNA reviews all available information. The final recommendation is sent to you, the Claims Administrator and the physician. The Plan Administrator makes the final decision regarding reimbursement.

Please Remember….

It is the employee's responsibility to call the Managed Benefits Program Coordinator when required. Asking the hospital, doctor or anyone to call does not relieve the employee of his responsibility - if the other party does not call.

PHYSICAL EXAMINATIONS
The Plan will have the right and opportunity to have a physician or dentist of its choice examine any person for whom certification or benefits have been requested. This will be done at all reasonable times while certification or a claim for benefits is pending or under review. This will be done at no cost to you.

LARGE CASE MANAGEMENT PROGRAM
This Program provides special benefit provisions whenever the Plan's Claims Administrator and your Managed Benefits Program Coordinator identify certain large claim situations. Examples of illness, injury or large catastrophic claims (called "large claim identifiers") which will be referred to the Managed Benefits Program Coordinator include:

• Premature and Multiple Births
• Neonatal Illnesses
• Chronic Neurological Diseases (Multiple Sclerosis, ALS-Lou Gehrig's Disease,
  Muscular Dystrophy)
• Major Trauma and Multiple Fractures
• Brain Injury
• Spinal Cord Injury
• Amputation
• Leukemia
• Immune Deficiency Syndromes (AIDS, Lupus, and Crohn's Disease)
• Severe Bums
• Stroke (CVA)
• Chronic Obstructive Pulmonary Disease (COPD)
• Any claim expected to exceed $25,000 in claim costs
• Any claim expected to exceed 30 days of in-patient care

When a large claim identifier occurs, the Managed Benefits Program Coordinator will be contacted to determine if a long-term plan of care needs to be developed in consultation with the patient’s attending Physician(s).

Notice of a large claim identifier occurrence can be provided to the Managed Benefits Program Coordinator by the patient, the Employee, the Employer or the Claims Administrator. Immediate notification of a large claim identifier is essential to an effective long-term plan of care.

NATIONAL MEDICAL EXCELLENCE PROGRAM (NME)
The NME Program coordinates all solid organ and bone marrow transplants and other specialized care that cannot be provided within an NME Patient's local geographic area. When care is directed to a facility ("Medical Facility") more than 100 miles from the person's home, this Plan will pay a benefit for Travel and Lodging Expenses, but only to the extent described below.

TRAVEL EXPENSES
These are expenses incurred by an NME Patient for transportation between his or her home and the Medical Facility to receive services in connection with a procedure or treatment.

Also included are expenses incurred by a Companion for transportation when traveling to and from an NME Patient's home and the Medical Facility to receive such services.

LODGING EXPENSES
These are expenses incurred by an NME Patient for lodging away from home while traveling between his or her home and the Medical Facility to receive services in connection with a procedure or treatment.

The benefit payable for these expenses will not exceed the Lodging Expenses Maximum per person per night.

Also included are expenses incurred by a Companion for lodging away from home:

• while traveling with an NME Patient between the NME Patient's home and the Medical Facility to receive services in connection with any listed procedure or treatment; or

• when the Companion's presence is required to enable an NME Patient to receive such services from the Medical Facility on an inpatient or outpatient basis.

The benefit payable for these expenses will not exceed the Lodging Expenses Maximum per person per night.

For the purpose of determining NME Travel Expenses or Lodging Expenses, a hospital or other temporary residence from which an NME Patient travels in order to begin a period of treatment at the Medical Facility, or to which he or she travels after discharge at the end of a period of treatment, will be considered to be the NME Patient's home.

TRAVEL AND LODGING BENEFIT MAXIMUM
For all Travel Expenses and Lodging Expenses incurred in connection with any one procedure or treatment type:

• The total benefit payable will not exceed the Travel and Lodging Maximum per episode of care.
• Benefits will be payable only for such expenses incurred during a period which begins on the day a covered person becomes an NME Patient and ends on the earlier to occur of:

  one year after the day the procedure is performed; and

  the date the NME Patient ceases to receive any services from the facility in connection with the procedure.

Benefits paid for Travel Expenses and Lodging Expenses do not count against any person's Maximum Benefit.

LIMITATIONS
Travel Expenses and Lodging Expenses do not include, and no benefits are payable for, any charges which are included as Covered Medical Expenses under any other part of this Plan.

Travel Expenses do not include expenses incurred by more than one Companion who is traveling with the NME Patient.

Lodging Expenses do not include expenses incurred by more than one Companion per night.