Other covered expenses under the Aetna HealthFund™ (HRA) option include:
• Room and board at the semiprivate room rate and other medically necessary services and supplies the hospital furnishes to the patient
• Room and board at the private room rate is only covered if isolation is medically required, or if no semiprivate rooms are available
• Outpatient charges
• Charges made by an RN or a nursing agency for skilled nursing care if approved in advance
• Drugs and medicines that by law require a physician's prescription
• Diagnostic laboratory and X-ray examinations, radium and radioactive isotope therapy
• Anesthesia and oxygen
• Rental or purchase of durable medical or surgical equipment necessary for the medical or surgical treatment of a covered disease or injury
• Medically necessary local ambulance or air ambulance service to the nearest facility offering medically required services
• Artificial limbs and artificial eyes when part of an approved treatment plan
• At least 48 hours of hospitalization following a vaginal delivery and 96 hours following a Cesarean-section delivery
• Blood transfusions
• Birth control pills, injections or devices that are medically prescribed and not considered experimental or investigational (See Medical Benefit Exclusions and Limitations)
• Physical therapy that is prescribed as to type, frequency and duration by the attending medical doctor and from which there is the reasonable expectation of functional improvement. See Outpatient Physical and Occupational Therapy Benefits section for coverage limits.
• Reconstructive breast surgery following mastectomy, including reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications of all stages of mastectomy, including swelling associated with the removal of lymph nodes
Allergy Testing and Treatment
Benefits for allergy testing and treatment:
• Network coinsurance is 90%, after the deductible is met
• Non-network coinsurance is 50% of the Recognized Charge, after the deductible is met
Chiropractic Services
To be covered, visits must be for the treatment of:
• Misalignment or dislocation of the spine
• Strained muscles or ligaments related to spinal disorders or the extremities Benefits for chiropractic services:
• Network coinsurance is 90%, after the deductible is met
• Non-network coinsurance is 50% of the Recognized Charge, after the deductible is met
• Combined annual network and non-network maximum of 35 visits per person per calendar year
Durable Medical Equipment
If you require durable medical equipment, the following applies under the Aetna HealthFund™ (HRA) option:
• Network coinsurance is 90%, after the deductible is met
• Non-network coinsurance is 50% of the Recognized Charge, after the deductible is met Durable medical equipment will only be eligible for coverage if it is considered medically necessary. Contact Aetna to determine what durable medical equipment is covered
Home Health Care
If you or your covered dependents have been seriously ill or hospitalized and require continued care after release, you may be able to receive nursing care, medical supplies and/or therapy services at home under the Aetna HealthFund™ (HRA) option.
To receive network benefits, you or your covered dependents must meet three conditions:
• Be confined at home while receiving care
• Receive care through a home health agency
Benefits for home health care:
• Network coinsurance is 90%, after the deductible is met
• Non-network coinsurance is 50% of the Recognized Charge, after the deductible is met
• Include part-time or intermittent home nursing care by an RN or LVN
• Include part-time or intermittent home health-aide services that consist primarily of caring for the individual
• Include physical, occupational and speech therapy
Include medical supplies, drugs and medicines prescribed by a physician, and laboratory services provided by or on behalf of a hospital. This is only to the extent that they would have been
covered under this benefit option if the individual had remained in the hospital.
The maximum number of home health care visits covered in a calendar year is 120. Each visit of up to four hours by an RN, LVN, aide or therapist will be considered as one visit. Care must require skilled nursing interventions.
Home health care expenses not covered:
• Services, treatments, or supplies not covered under your home health program
• Services of a person who ordinarily resides in your home or is a member of your family or your spouse or domestic partner’s family
• Services of a social worker
• Custodial care
• Transportation services
• Infusion therapy services
Hospice Care Program
Under the Aetna HealthFund™ (HRA) option, if you or any of your covered dependents should become terminally ill (that is, diagnosed with twelve months or less to live), you may be eligible for a variety of hospice services and supplies. You must use an Aetna network provider to receive network
reimbursement. Contact Aetna for additional information. Benefits for hospice care services:
• Network coinsurance is 80%, after the deductible is met
• Non-network coinsurance is 50% of the Recognized Charge, after the deductible is met
• Include services provided on an outpatient basis by a hospice care agency/home health agency for:
o Physical and occupational therapy; o Medical supplies;
o Prescription drugs; o Dietary counseling; and o Psychological counseling There is a 30-day lifetime limit for hospice care.
Covered expenses also include medical social services provide by a hospice care agency under the direction of a physician, including assessment of your social, emotional and medical needs, and your home and family situation; identification of available community resources; and assistance provided to you to obtain resources to meet your assessed needs. Consultation or case management services provided by a physician and services provided by a physical or occupational therapist who is not an employee of a hospice care agency are covered provided the agency retains responsibility for your care. Services not included under hospice care:
• Funeral arrangements
• Pastoral counseling
• Financial or legal counseling - this includes estate planning and the drafting of a will
• Homemaker or caretaker services (including sitter or companion services for either the individual who is ill or other members of the family), transportation, house cleaning and maintenance of the house
Note: Some of these excluded counseling services are available through the Employee Assistance
Program (EAP).
Jaw Joint Disorder Treatment
The Aetna HealthFund™ (HRA) option covers services provided by a physician, hospital or surgery center for the diagnosis and surgical treatment of jaw joint disorder. Charges for non-surgical treatment (other than those related to the diagnosis) of a jaw disorder are not covered. A jaw joint disorder is a painful condition:
• Of the jaw joint itself, such as temporomandibular joint dysfunction (TMJ) syndrome; or
• Involving the relationship between the jaw joint and related muscles and nerves such as myofacial pain dysfunction (MPD).
Oral and Maxillofacial Treatment (Mouth, Jaws and Teeth)
Covered expenses include charges made by a physician, a dentist and hospital for:
• Non-surgical treatment of infections or diseases of the mouth, jaw joints or supporting tissues;
• Services and supplies for treatment of, or related conditions of, the teeth, mouth, jaws, jaw joints or supporting tissues (this includes bones, muscles, and nerves) for surgery needed to:
o Treat a fracture, dislocation, or wound;
o Cut out teeth that are partly or completely impacted in the bone of the jaw; teeth that will not erupt through the gum; other teeth that cannot be removed without cutting into bone; the roots of a tooth without removing the entire tooth; cysts, tumors, or other diseased tissues; and
o Cut into gums and tissues of the mouth. This is only covered when not done in connection with the removal, replacement or repair of teeth.
o Alter the jaw, jaw joints, or bite relationships by a cutting procedure when appliance therapy alone cannot result in functional improvement.
• Hospital services and supplies received for a stay required because of your condition.
• Dental work, surgery and orthodontic treatment needed to remove, repair, restore or reposition: o Natural teeth damaged, lost, or removed; and
Any such teeth must have been free from decay or in good repair, and are firmly attached to the jaw bone at the time of the injury.
The treatment must be completed in the year of the accident or in the next year.
If crowns, dentures, bridges, or in-mouth appliances are installed due to injury, covered expenses only include charges for:
o The first denture or fixed bridgework to replace lost teeth; o The first crown needed to repair each damaged tooth; and
o An in-mouth appliance used in the first course of orthodontic treatment after the injury. Dietitian Consultations
Under the Aetna HealthFund™ (HRA) option, medical nutrition therapy, provided by a qualified network dietitian, is available to you and your covered dependents in certain cases in which dietary adjustment has a therapeutic role (e.g., diabetes) and is prescribed by a physician and furnished by a provider (e.g., a registered dietician, licensed nutritionist or other qualified licensed health professions such as nurses who are trained in nutrition) recognized under this option. The sessions feature interactive and
individualized education and counseling.
For you or your covered family members to be eligible, you must be an Aetna HealthFund™ (HRA) option participant and have a diagnosis such as (but not limited to):
• Cancer (e.g., breast, colon, lung or stomach)
• Cardiovascular Disease
o Congestive heart failure, chronic o Coronary artery disease
o Hypercholesterolemia (high cholesterol) o Hyperlipidemia (abnormal blood fats) o Hypertension (chronic high blood pressure) o Hypertension in pregnancy
• Diabetes/endocrine disorders o Diabetes, insulin-dependent o Diabetes, noninsulin-dependent
o Diabetes, gestational (during pregnancy) o Hypoglycemia, reactive (low blood sugar)
• Gastrointestinal disorders
• HIV infection with HIV-related complications
• Food allergy that causes abnormal weight loss or acute asthma
• Failure to thrive/malnutrition/eating disorders
• Obesity
To determine eligibility, contact Aetna through TI HR Connect at 888-660-1411. When you call, you may be asked questions to establish your records and to determine if medical nutrition therapy is appropriate for you at this time.
You may have up to four visits a year for an eligible medical problem. If a new problem requiring medical nutrition therapy develops in the same calendar year, you may be eligible for an additional four visits. During your initial visit, the dietitian will assess your food preferences and eating patterns. The dietitian will also help you understand how your food and lifestyle choices affect your medical condition and will assist you in setting goals to meet your individual needs. Follow-up visits will include checking to see if your diet plan is still right for you, a review of progress toward goals and additional education. After each visit, the dietitian will send your doctor a brief report.
The coinsurance is 90% of the cost after the deductible is met for network benefits. Dietitian visits outside the network are not covered.
Outpatient Physical and Occupational Therapy Benefits
Benefits for outpatient physical and occupational therapy (services provided in the doctor/therapist’s office or in an outpatient facility):
• Network coinsurance is 90%, after the deductible is met
• Non-network coinsurance is 50% of the Recognized Charge, after the deductible is met
• Combined annual network and non-network maximum of 100 visits per person per calendar year
Treatment for Loss or Impairment of Speech
Speech therapy services are eligible for coverage under the Aetna HealthFund™ (HRA) option when all the following criteria are met:
• Used in the treatment of communication or swallowing impairment;
• Prescribed by a licensed physician and rendered by a licensed/certified speech therapist;
• Used to achieve a specific diagnosis-related or therapeutic goal; and
• Medical records must indicate the patient has a likely expectation of achieving measurable improvement in a predictable period of time
Benefits for outpatient speech therapy for treatment of loss or impairment of speech:
• Network coinsurance is 90%, after the deductible is met
• Non-network coinsurance is 50% of the Recognized Charge, after the deductible is met
• Combined annual network and non-network maximum of 50 visits per person per calendar year Skilled Nursing Facility
Benefits for a skilled nursing facility (care must be non-custodial):
• Network coinsurance is 80%, after the deductible is met
• Combined annual network and non-network maximum of 100 days per person per calendar year Skilled nursing facility means a facility primarily engaged in providing skilled nursing services and other therapeutic services, and which is 1) licensed in accordance with state law (where the state law provides for licensing of such facility); or 2) Medicare or Medicaid eligible as a supplier of skilled nursing care. Services not included under a skilled nursing facility:
• Treatment of: drug addiction; alcoholism; senility; mental retardation; or any other mental illness; and
• Daily room and board charges over the semi private rate Human Organ or Tissue Transplants
Aetna has a network of providers for transplants that have entered into an agreement with Aetna to provide services or care related to organ and tissue transplants at pre-established rates. The network level of benefits is paid only for a treatment received at a facility designated by the Aetna HealthFund™ (HRA) option as an Institute of Excellence™ (IOE) for the type of transplant being performed. Each IOE facility has been selected to perform only certain types of transplants.
Through the IOE network, you will have access to a provider network that specializes in transplants. Benefits may vary if an IOE facility or non-IOE or out-of-network provider is used. In addition, some expenses are payable only within the IOE network. The IOE facility must be specifically approved and designated by Aetna to perform the procedure you require. Each facility in the IOE network has been selected to perform only certain types of transplants based on quality of care and successful clinical outcomes.
Services obtained from a facility that is not designated as an IOE for the transplant being performed will be covered as out-of-network services and supplies, even if the facility is a network facility or IOE for other types of services.
If you live in an area where a transplant network is available, you should use network providers in order to receive the highest level of reimbursement.
Patients who reside outside of the transplant network geographic area may be eligible for coverage of pre-approved travel expenses. Contact Aetna to determine whether you reside in a transplant network geographic area.
Benefits for network and non-network transplants:
• Network coinsurance for a treatment received from a facility that is designated as an Institute of Excellence™ for the transplant being performed is 80%, after the deductible is met
• Non-network coinsurance (services obtained from a facility that is NOT designated as an Institute of Excellence™ for the transplant being performed) is 50% of the Recognized Charge after the deductible is met
Covered expenses include charges incurred during a transplant occurrence. The following will be considered to be one transplant occurrence once it has been determined that you or one of your dependents may require an organ (organ means solid organ; stem cell; bone marrow; and tissue) transplant:
• Heart;
• Lung;
• Simultaneous Pancreas Kidney (SPK);
• Pancreas;
• Kidney;
• Liver;
• Intestine;
• Bone Marrow/Stem Cell;
• Multiple organs replaced during one transplant surgery;
• Tandem transplants (Stem Cell);
• Sequential transplants;
• Re-transplant of same organ type within 180 days of the first transplant; and
• Any other single organ transplant, unless otherwise excluded under the Aetna HealthFund™ (HRA) option.
The following will be considered to be more than one transplant occurrence:
• Autologous blood/bone marrow transplant followed by allogenic blood/bone marrow transplant (when not part of a tandem transplant);
• Allogenic blood/bone marrow transplant followed by an autologous blood/bone marrow transplant (when not part of a tandem transplant);
• Re-transplant after 180 days of the first transplant;
• Pancreas transplant following a kidney transplant;
• A transplant necessitated by an additional organ failure during the original transplant surgery/process; and
• More than one transplant when not performed as part of a planned tandem or sequential transplant, (e.g., a liver transplant with subsequent heart transplant).
The Aetna HealthFund™ (HRA) option covers:
• Charges made by a physician or transplant team;
• Charges made by a hospital, outpatient facility or physician for the medical and surgical expenses of a live donor, but only to the extent not covered by another plan or program;
• Related supplies and services provided by the facility during the transplant process. These services and supplies may include: physical, speech and occupational therapy; biomedicals and immunosuppressants; home health care expenses and home infusion services;
• Charges for activating the donor search process with national registries;
• Compatibility testing of prospective organ donors who are immediate family members. For the purpose of this coverage, an “immediate” family member is defined as a first-degree biological relative. These are your biological parents, siblings or children; and
• Inpatient and outpatient expenses directly related to a transplant.
Covered transplant expenses are typically incurred during the four phases of transplant care described below. Expenses incurred for one transplant during these four phases of care will be considered one transplant occurrence.
A transplant occurrence is considered to begin at the point of evaluation for a transplant and end either 180 days from the date of the transplant or upon the date you are discharged from the hospital or outpatient facility for the admission or visit(s) related to the transplant, whichever is later.
The four phases of one transplant occurrence and a summary of covered transplant expenses during each phase are:
1. Pre-transplant evaluation/screening: Includes all transplant-related professional and technical components required for assessment, evaluation and acceptance into a transplant facility’s transplant program;
2. Pre-transplant/candidacy screening: Includes HLA typing/compatibility testing of prospective organ donors who are immediate family members;
3. Transplant event: Includes inpatient and outpatient services for all covered transplant related health services and supplies provided to you and a donor during the one or more surgical
procedures or medical therapies for a transplant; prescription drugs provided during your inpatient stay or outpatient visit(s), including bio-medical and immunosuppressant drugs; physical, speech or occupational therapy provided during your inpatient stay or outpatient visit(s); cadaveric and live donor organ procurement; and
4. Follow-up care: Includes all covered transplant expenses; home health care services; home infusion services; and transplant-related outpatient services rendered within 180 days from the date of the transplant event.
If you are a participant in the IOE program, the program will coordinate all solid organ and bone marrow transplants and other specialized care you need. Any covered expenses you incur from an
IOE facility will be considered network care expenses.
Limitations: Unless specified above, not covered under this benefit are charges incurred for:
• Outpatient drugs including bio-medicals and immunosuppressants not expressly related to an outpatient transplant occurrence;
• Services that are covered under any other part of the Aetna HealthFund™ (HRA) option;
• Services and supplies furnished to a donor when the recipient is not covered under this option;