Item 4EItem 4E
M E M O R A N D U M
July 30, 2019
TO: Shana Yelverton, City Manager
FROM: Stacey Black, Director of Human Resources
SUBJECT: Approve a contract renewal and change order with Aetna to provide
employee health insurance, dental insurance, and vision insurance
benefits for Plan Year October 1, 2019 through September 30, 2020.
Action
Requested: Approve a contract renewal and change order with Aetna to provide
employee health insurance, dental insurance and vision insurance
benefits for Plan Year October 1, 2019 to September 30, 2020.
Background
Information: Aetna became the City’s health insurance provider on October 1, 2016
following a competitive bidding process, and in June, the City received
its health insurance renewal from Aetna.
Over the last 12 months, the City has experienced a 48% increase in
medical and prescription claims. In addition, Aetna reported that the City
is currently experiencing 31 large, ongoing claims. As a result, Aetna’s
initial renewal offer proposed a 33.08% rate increase. Following
negotiations, Aetna reduced its renewal offer to a 16% rate increase with
no plan design changes.
To further reduce the rate increase, the renewal proposes enacting a
change order to bundle dental and vision insurance with the health
insurance and proposes making plan changes.
Multiline Bundle Discount: If the City also purchases dental and
vision insurance from Aetna, they will provide a 2.5% multiline
rate discount on the health plan. The estimated savings is
approximately $51,000.
Plan Changes: The renewal proposes making plan changes to
the two most expensive health insurance plans. The annual
individual deductible will increase by $500 and the family
deductible will increase by $1,000. This reduces the overall
health insurance rate increase to 10.38%.
Shana Yelverton, City Manager Item 4E
July 30, 2019
Page 2
The below illustration shows the original proposal from Aetna and the
final proposal with the multiline discount and plan changes savings.
Aetna’s proposed PPO dental plan is similar to the City’s current plan
and is 20% rate increase over the current plan. The estimated cost of
the rate increase is $23,000. As part of the negotiation process, Aetna
agreed to provide a credit equivalent to the first month of dental
premiums, which is approximately $21,990. Therefore, the estimated net
annual increase for dental insurance is $1,010.
Aetna’s proposed vision plan is similar to the City’s current vision plan
and reflects a rate increase of approximately 9%. Vision insurance is
optional, and employees contribute 100% of the cost.
The City’s experience with Aetna has been favorable and very few
service complaints have been received from employees. After a review
of the claims data and given the favorable experience, Staff
recommends Council approve the proposed health insurance renewal
and change order for dental and vision insurance.
Financial
Considerations:
Coverage Estimated Annual
City Contribution
Estimated City
Increase
Health Insurance $3,815,783 $197,000
Dental Insurance $138,953 $1,010
Vision Insurance $0 $0
The proposed insurance plan costs will be included in the proposed
budget for Fiscal Year 2020.
Shana Yelverton, City Manager Item 4E
July 30, 2019
Page 3
Strategic Link: Performance Management and Service Delivery: attract, develop and
retain a skilled workforce.
Citizen Input/
Board Review: N/A
Legal Review: N/A
Alternatives: Deny contract with Aetna and seek alternative options.
Supporting
Documents: The following supporting documents are attached:
• Aetna Change Order
• Aetna Health Renewal
• Aetna Dental Proposal
• Aetna Vision Proposal
Staff
Recommendation: Approve a contract renewal and change order with Aetna to provide
employee health insurance, dental insurance, and vision insurance
benefits for Plan Year October 1, 2019 through September 30, 2020.
Our simplified navigation center, personal onboarding and data analytics help ensure that members
receive the proper care they need to reach their health ambitions.
Texas Health Aetna ER Doc app.
a more personalized, connected care experience.
Texas Health Aetna is the brand name used for products and services provided by Texas Health +
Aetna Health Insurance Company and Texas Health + Aetna Health Plan Inc.
Health benefits and health insurance plans are offered and/or underwritten by Texas Health +
Aetna Health Plan Inc. and Texas Health + Aetna Health Insurance Company (Texas Health Aetna).
Texas Health Aetna is an affiliate of Texas Health Resources and of Aetna Life Insurance Company
and its affiliates (Aetna). Aetna provides certain management services to Texas Health Aetna.
Each insurer has sole financial responsibility for its own products.
Aetna and Texas Health Aetna have various programs for compensating producers (agents,
brokers and consultants). If you would like information regarding compensation programs for
which your producer is eligible, payments (if any) which Aetna or Texas Health Aetna have made
to your producer, or other material relationships your producer may have with us, you may
contact your producer or your Aetna or Texas Health Aetna account representative.
texashealthaetna.com
The information contained in this proposal is confidential and should not be shared with anyone
other than your broker or benefit plan consultant.
By working closely with local health systems like Southwestern Health Resources, members get
Convenient to access local hospitals, local physicians and local non-clinical care network
Members get timely access to appointments with primary care doctors, often with same-day or next
day availability. After-hours care and 24/7 virtual visits are also available through the
Care that connects all of your providers for a more personalized holistic view of your needs
As a member of Texas Health Aetna, you and your employees can enjoy:
A simple and seamless experience designed to support your health ambitions
Affordability and efficiency
We've negotiated improved pricing for many providers across the Dallas-Fort Worth metroplex to
help drive down costs and create efficiencies.
experience for you and your employees in the Dallas-Fort Worth metroplex.
We coordinate both clinical and non-clinical care on a local level to help get members healthy -
and help keep them healthy. And we are aligned under one objective: helping members
achieve their health ambitions. By combining our capabilities and bringing down administrative
barriers, we can help ensure you and your employees have seamless access to care.
At Texas Health Aetna we believe that great health starts with great local care that is personalized,
connected and affordable. Texas Health Aetna represents two leading health care organizations,
Texas Health Resources and Aetna, coming together to fundamentally transform the health care
Page 1October 2017
Proprietary
Catherine Walsh
Sr Account Manager
2777 Stemmons Freeway
Dallas, TX 75207
Phone: 214-200-8550
WalshC1@aetna.com
City Of Southlake
Michelle Sunday
1400 Main St, Ste 260
Southlake, TX 76092
To Whom It May Concern:
Thank you for allowing us to serve your health insurance and health benefit needs during the past year.
This package provides information to help you develop the future benefits program for City Of Southlake.
As we approach the anniversary of our relationship in the journey to better health, we are pleased to
present you with this renewal for your 2019 policy period.
It's important to understand the full financial picture of your benefit plan.
■ Future Program Costs
This section illustrates the cost projections to operate your current benefit program for the
period 10/1/2019 through 9/30/2020.
■ Fully Insured Medical Plans
This renewal reflects both the premium and the producer service fee.
■ Caveats
Our renewal offer is contingent upon the parameters outlined here. It is important to note that
deviations from these assumptions may result in additional charges and/or adjustments on our
Medical quotations. Please review this section thoroughly.
If there are no changes that impact the conditions of this renewal as outlined in our Caveats
section, the rates will remain in effect through September 30, 2020.
Sincerely,
Catherine Walsh Julie Tam
Catherine Walsh Julie Tam
Sr Account Manager Sr Underwriting Cnslt
Each insurer has sole financial responsibility for its own products.
Health benefits and health insurance plans contain limitations and exclusions.
If you'd like to make any plan changes or if you have any questions, please contact me by September 01, 2019 at 214-200-
8550. It's been a pleasure working with you and I look forward to our continued relationship.
June 20, 2019
Therefore, the enclosed package provides the following important information about the cost of your current program and
the value we bring to you and your company.
For the period 10/1/2019 through 9/30/2020 the cost to operate your current medical plans will increase 13.50%
compared to the current rate.
Renewal Letter06/20/2019
#Proprietary
Contact Information
Email:
Assumptions
Contract State:Lives:
Medical Pooling Level:Sic Code:
Producer Service Fee:Mem/EE Ratio:
Health Insurance Provider Fee%*:Rx Formulary:
Proposed Rates Effective Date:End Date:
Enhanced Wellness Package is included in the Proposed Rates. Total Amount Due Includes 4.2% Producer Service Fee**
This proposal includes a cross sell discount***
Clarifications
*The Affordable Care Act imposed the health insurance provider fee effective January 1 2014. This rate quote includes, where permitted,
an estimate proportionate allocation of expenses associated with these fees.
**The proposed rates include our premium and Producer Service Fee as requested. Producer Service Fee will be removed from Total
Amount Due if Policyholder and/or Producer do not elect our company to serve as billing and collection agent. Total Amount Due will
reflect executed Billing & Collection Agreement.
The Medical Pooling Level indicated in the assumptions above represents what was used in your pricing based on company
standards for your market and case size. This may be subject to change.
***Your above rates include a cross sell discount for the following products: Vision and Dental
$395,425.46
10.38%
$4,745,105.52
$52,446.34 9.90%
331
$358,227.13
$1,708.13 9.90%
$1,508.98 9.90%
$2,504.74 9.90%
$256,326.74 9.47%
OA POS (Managed Choice)
OAMC Option 1 Premier Rx
$765.97 9.90%
$1,522.96 9.47%
$1,345.38 9.47%
$2,233.20 9.47%
$37,015.44 13.50%
OA EPO (Elect Choice)
OAEC Option 2 Premier Rx
$682.94 9.47%
$1,403.83 13.50%
$1,240.14 13.50%
$2,058.51 13.50%
$49,636.94 13.50%
Texas Health EPO C Open Access Network Only
OAEC THA Premier Rx
$629.52 13.50%
13.50%
$1,322.31 13.50%
$1,168.15 13.50%
$1,938.98 13.50%
Total % Change 13.50%
Proposed Annual Total Amount Due $4,879,173.84
Scenario: Alternative Rates 3
Proposed Rates % Change
HSA OA POS (Managed Choice)
OAMC HDHP Premier Rx
$592.96
Total Medical Lives 331
Current Monthly Total Amount Due $358,227.13
Proposed Monthly Total Amount Due $406,597.82
Family 5 $2,279.20 $2,586.96 13.50%
Total 39 $47,723.86 $54,168.08 13.50%
EE + SP 10 $1,554.32 $1,764.20 13.50%
EE + Children 6 $1,373.11 $1,558.52 13.50%
OA POS (Managed Choice)
OAMC Premier Rx
EE 18 $697.00 $791.12 13.50%
Family 43 $2,040.07 $2,315.54 13.50%
Total 212 $234,159.41 $265,777.36 13.50%
EE + SP 14 $1,391.25 $1,579.11 13.50%
EE + Children 50 $1,229.03 $1,394.98 13.50%
OA EPO (Elect Choice)
OAEC Premier Rx
EE 105 $623.88 $708.12 13.50%
Family 8 $1,813.62 $2,058.51 13.50%
Total 29 $32,611.95 $37,015.44 13.50%
EE + SP 0 $1,236.82 $1,403.83 13.50%
EE + Children 12 $1,092.61 $1,240.14 13.50%
Texas Health EPO C Open Access Network Only Plus
OAEC THA Premier Rx
EE 9 $554.63 $629.52 13.50%
Family 7 $1,708.31 $1,938.98 13.50%
Total 51 $43,731.91 $49,636.94 13.50%
EE + SP 5 $1,165.00 $1,322.31 13.50%
EE + Children 11 $1,029.18 $1,168.15 13.50%
HSA OA POS (Managed Choice)
OAMC HDHP Premier Rx
EE 28 $522.42 $592.96 13.50%
1.95%Premier
October 1, 2019 September 30, 2020
Coverage Lives Current Rates Proposed Rates % Change
TX 331
$175,000 9111
4.20%2.11
City Of Southlake
Account Manager:Catherine Walsh WalshC1@aetna.com
Telephone Number:214-200-8550
Prospective_Rates07/17/2019
#Proprietary
City Of Southlake
Proposed Plan Designs - Fully Insured Funding Effective Date: October 01, 2019
*Aetna Premier Formulary
Offers moderate savings and control. All generics are preferred plus more brands per class. Includes proven pharmacy
management techniques like precertification and step therapy. Customers can choose between Transition of Coverage or
Transition Fill. Specialty drugs must be filled at our Specialty Pharmacy Network. Coverage includes select over-the-counter drugs
and certain formulary exclusions apply. Some programs may not be available based on state regulations.
Covered drug lists can be found at: www.aetna.com/formulary
Aetna reserves the right to replace the stated formulary with a comparable formulary prior to the plan effective date,
so long as such change does not affect the proposed monthly premium rate. Aetna will notify the plan sponsor of a
change to a comparable formulary.
• Aetna standard policies and provisions will apply to all benefits not outlined above.
Rx Drug G/F/B $10/$35/$70/$150/$300
*Rx Formulary Aetna Premier Open
Emergency Room
Urgent Care
80% after $300 /
$75
80% after $300 /
50%
Hospital Outpatient 80%50%
Hospital Inpatient $1 50%
Office Visit Copay
Specialist Copay $25 / $50 50% / 50%
Member Payment Limit
Ind/Fam $3,000 / $6,000 $6,000 / $18,000
Deductible Ind/Fam $1,000 / $2,000 $2,000 / $6,000
Coinsurance 80%50%
Plan Features OAMC Premier Rx
In Out
*Rx Formulary Aetna Premier Open Aetna Premier Open Aetna Premier Open
Rx Mail Order Delivery $25.00/$87.50/$175.00/N/A/N/A $25.00/$87.50/$175.00/N/A/N/A $25.00/$87.50/$175.00/N/A/N/A
N/A / N/A
Rx Drug G/F/B $10/$35/$70/$150/$300 $10/$35/$70/$150/$300 $10/$35/$70/$150/$300
Emergency Room
Urgent Care 90% / 90% 90% / 50%80% after $300 /
$75 N/A / N/A 80% after $300 /
$75
80%N/A
N/A
Hospital Outpatient 90%50%80%N/A
Hospital Inpatient 90%50%80%N/A $1
$30 / $50 N/A / N/A
$9,999,999 /
$9,999,999
Office Visit Copay
Specialist Copay 90% / 90% 50% / 50% $30 / $50 N/A / N/A
Member Payment Limit
Ind/Fam $6,000 / $12,000 $12,500 /
$37,500 $5,000 / $10,000 $9,999,999 /
$9,999,999 $5,000 / $10,000
$1,500 / $3,000 N/A / N/A
N/A
Deductible Ind/Fam $3,000 / $6,000 $6,000 / $18,000 $1,500 / $3,000 N/A / N/A
Coinsurance 90%50%80%N/A 80%
In Out
Plan Features OAMC HDHP Premier Rx OAEC THA Premier Rx OAEC Premier Rx
In Out In Out
Benefit Summary_Current07/17/2019
#Proprietary
City Of Southlake
Proposed Plan Designs - Fully Insured Funding Effective Date: October 01, 2019
*Aetna Premier Formulary
Offers moderate savings and control. All generics are preferred plus more brands per class. Includes proven pharmacy
management techniques like precertification and step therapy. Customers can choose between Transition of Coverage or
Transition Fill. Specialty drugs must be filled at our Specialty Pharmacy Network. Coverage includes select over-the-counter drugs
and certain formulary exclusions apply. Some programs may not be available based on state regulations.
Covered drug lists can be found at: www.aetna.com/formulary
Aetna reserves the right to replace the stated formulary with a comparable formulary prior to the plan effective date,
so long as such change does not affect the proposed monthly premium rate. Aetna will notify the plan sponsor of a
change to a comparable formulary.
• Aetna standard policies and provisions will apply to all benefits not outlined above.
Rx Drug G/F/B $10/$35/$70/$150/$300
*Rx Formulary Aetna Premier Open
Emergency Room
Urgent Care
80% after $300 /
$75
80% after $300 /
50%
Hospital Outpatient 80%50%
Hospital Inpatient 80%50%
Office Visit Copay
Specialist Copay $25 / $50 50% / 50%
Member Payment Limit
Ind/Fam $3,500 / $7,000 $6,500 / $19,500
Deductible Ind/Fam $1,500 / $3,000 $2,500 / $7,500
Coinsurance 80%50%
Plan Features OAMC Option 1 Premier Rx
In Out
*Rx Formulary Aetna Premier Open Aetna Premier Open Aetna Premier Open
Rx Mail Order Delivery $25.00/$87.50/$175.00/N/A/N/A $25.00/$87.50/$175.00/N/A/N/A $25.00/$87.50/$175.00/N/A/N/A
N/A / N/A
Rx Drug G/F/B $10/$35/$70/$150/$300 $10/$35/$70/$150/$300 $10/$35/$70/$150/$300
Emergency Room
Urgent Care 90% / 90% 90% / 50%80% after $300 /
$75 N/A / N/A 80% after $300 /
$75
80%N/A
N/A
Hospital Outpatient 90%50%80%N/A
Hospital Inpatient 90%50%80%N/A $1
$30 / $50 N/A / N/A
$9,999,999 /
$9,999,999
Office Visit Copay
Specialist Copay 90% / 90% 50% / 50% $30 / $50 N/A / N/A
Member Payment Limit
Ind/Fam $6,000 / $12,000 $12,500 /
$37,500 $5,000 / $10,000 $9,999,999 /
$9,999,999 $5,500 / $11,000
$2,000 / $4,000 N/A / N/A
N/A
Deductible Ind/Fam $3,000 / $6,000 $6,000 / $18,000 $1,500 / $3,000 N/A / N/A
Coinsurance 90%50%80%N/A 80%
In Out
Plan Features OAMC HDHP Premier Rx OAEC THA Premier Rx OAEC Option 2 Premier Rx
In Out In Out
Benefit Summary_Alt Rates 307/17/2019
#Proprietary
Network Services
Care Management
Member Resources
Wellness Programs and Services
Allowances
Pharmacy Programs
Reporting
Behavioral Health
Network Services
−
−
*Available to patients who receive care from a Sutter-affiliated medical foundation.
for non-emergency issues via instant secure messaging or scheduled video conference. The app was developed
Texas Health Aetna ER Doc Cost
The Texas Health Aetna ER Doc is a healthcare communications platform that provides access to consultations Included
lower coinsurance and deductible charges. In addition, the contracted rate component of NAP provides
similar benefits when members receive out-of-network services involuntarily (e.g., emergencies). The claim
experience for your quoted products also includes NAP access fees (a percentage of NAP savings achieved).
claims) often results in eliminating certain types of charges prior to claim adjudication.
These programs not only save money on eligible claims for your plan but also can help your employees see
•Itemized Bill Review (IBR)
Review of large facility charges that meet certain criteria (including certain in-network, inpatient
Provides a reasonable charge allowance review for most inpatient and outpatient out-of-network
facility claims where the NAP contracted rate is not available.
Review (IBR) Review (IBR) components of Aetna's National Advantage™ Program (NAP).
•Facility Charge Review (FCR)
NAP Flex Cost
Your plan and your employees can save money with the Facility Charge Review (FCR) and Itemized Bill Included
Program Summary - Description of Services
AbleTo Network - subject to member cost share Included Included Included Included
Applied Behavioral Analysis (ABA) Included Included Included Included
Managed Behavioral Health Included Included Included Included
Utilization Management Reporting Included Included Included Included
Step Therapy Included Included Included Included
Choose Generics with Dispense As Written Override Included Included Included Included
Annual Wellness Allowance - $15,000 Included Included Included Included
Aetna Healthy Commitments℠ - Enhanced Wellness
Package Included Included Included Included
Enhanced Customer Servicing Framework Included Included Included Included
Aetna Navigator™Included Included Included Included
Member Website and Mobile Experience Included Included Included Included
24/7 Call Service Included Included Included Included
Regional Case Management Included Included Included Included
Aetna's CareEngine-Powered PHR Included Included Included Included
Enhanced Clinical Review Included Included Included Included
Aetna Maternity Program Included Included Included Included
MedQuery® with Member Messaging Included Included Included Included
Aetna Health Connections - Disease Management℠Included Included Included Included
National Medical Excellence Program® - Transplant
Coordination Included Included Included Included
Teladoc® Included Included Included Included
Nap Flex Included Included Included Included
City Of Southlake
Programs and Services - Fully Insured Funding Effective Date: October 01, 2019
Program Summary
OAMC
HDHP
Premier Rx
OAEC THA
Premier Rx
OAEC
Premier Rx
OAMC
Premier Rx
Programs and Services FI06/20/2019
#Proprietary
City Of Southlake
Programs and Services - Fully Insured Funding Effective Date: October 01, 2019
You’ll see consistency in the coordination of care for transplants with our National Medical Excellence
Program®. This case management program provides our members with:
• Access to care through our nationwide network of participating health care providers and hospitals
recognized for successful clinical outcomes
• Specialized case management by nurses experienced with transplants and complex care
• Allowances for transportation and lodging for the patient and one companion may be available if
preapproved by National Medical Excellence and the transplant care is received in an Institutes of
Excellence™ (IOE) facility more than 100 miles from home
• Coordination of follow-up care
Care Management
MedQuery® Member Messaging
An optional program of MedQuery that includes sending a consumer version of the care consideration by letter to
the member. This letter encourages the member to call his or her doctor to discuss the care consideration and is
the CareEngine applies over 9,000 clinical rule sets that unite a broad range of conditions to a single, combined
patient medical record. These include medical claims, pharmacy, lab results, and self-reported data.
Cost
Included
you and your employees.
MedQuery is powered by our patented CareEngine® technology. To find opportunities to improve patient care,
guidelines.
The program addresses over 35 chronic conditions and uses the MedQuery safety program to generate
recommendations for care (care considerations). It helps improve health outcomes and in turn lowers costs for
chronic conditions achieve healthy outcomes through advanced tools, techniques and systems. We personalize
the condition coaching for our members to motivate and empower them to change their behaviors and therefore
reduce health risks. We offer member education based on condition-specific assessments of clinical practice
Aetna Health ConnectionsSM Disease Management Cost
Our Aetna Health ConnectionsSM Disease Management program helps your employees and their families with Included
Included
https://www.teladoc.com/businesses/health-plans/
Accessed November 10, 2017.
National Medical Excellence Program® Cost
Teladoc has an average savings of $472 per episode of care.1 Video consults not available in all states due to state
regulations.
Citation: 1 Teladoc® 2017. Only Teladoc delivers these episode-of-care savings. Available at
We will continue to encourage using Teladoc®. It’s convenient for your employees to talk with a physician
during their lunch break and then pick up their prescription after work. At only $40 per consultation,
And with the recent addition of behavioral health, dermatology and caregiver services to Teladoc, your
employees have even more time-saving options available to them.
room and urgent care clinics.
Using Teladoc, members can talk with a doctor during their lunch break and then pick up their prescription
after work.
Teladoc® offers 24/7 access to a national network of physicians. They can diagnose, treat and prescribe Included
medication for many common, non-emergency medical issues via phone or online video at a lower cost
when visiting a doctor in person is not necessary. Teladoc helps prevent unnecessary visits to the emergency
to connect via secure instant message or to schedule a video visit. The best news is there is no cost
to the member for the visit.
Teladoc® Cost
With Texas Health Aetna ER Doc, Texas Health Aetna members can now chat with a local ER Doc about
non-emergent issues any time, from anywhere. The Texas Health Aetna ER Doc app allows members
CirrusMD, ACT and the physicians made available through the Texas Health Aetna ER Doc app are independent
contractors and are neither agents nor employees of Texas Health Aetna, its affiliates or plans administered
by Texas Health Aetna.
and is serviced by a vendor, CirrusMD Inc. (“CirrusMD”). Texas Health Aetna has contracted with Acute Care
Transitions, LLP (“ACT”) to provide access to emergency medicine physicians in Texas through the app.
Programs and Services FI06/20/2019
#Proprietary
City Of Southlake
Programs and Services - Fully Insured Funding Effective Date: October 01, 2019
sent only after the care consideration is communicated to the treating physician, to allow the physician time to
evaluate the issue.
Personal Health Record
Our Personal Health Record (PHR) is a secure online tool that allows members to easily track and use important
personal health information such as:
* Medical Conditions
* Medications
* Tests and Procedures
* Allergies and more
It uses member data to provide a complete picture of health and makes it easy to share the information with doctors.
But our PHR is much more than an online home for health information. It's like having a personal health assistant
who tells members exactly how they can take better care of themselves. When it spots potential medical problems,
possible drug interactions or gaps in care (like missed tests or procedures), it will post a message. The doctor will
also get an alert if it's urgent.
Regional Case Management
Manage or prevent major health events with early intervention. Through Aetna’s integrated systems and
processes, we can find at-risk members quickly using:
• Predictive modeling
• Claims data to find high-cost members
• Utilization management reviews
• Referrals from doctors and Aetna programs
Our Case Management program:
• Improves transition and coordination between multiple providers and varying levels of care
• Reduces unnecessary medical costs and helps members get the care they need
• Maximizes effective use of plan benefits
• Educates members about tools and resources they can use to make health care
• Improves member understanding and management of their health care needs
• Identifies behavioral health concerns that may impact a member’s ability to achieve their health goals
Member Resources
Member Website and Mobile Experience Cost
Members have 24 hour access to our web and mobile experience, including our secure website and mobile app. Included
24/7 Call Service Cost
Members can speak with a Member Services representative 24 hours a day, 7 days a week. The service is Included
available every day except select holidays.
Included
Cost
accompanying members to doctor visits, care giver education and training, medication reconciliation.
Multi-Disciplinary Care Teams (MDCT) Cost
Locally based care team, including medical director, pharmacist, nurses, social workers and diabetic educators support Included
individuals and their families with complex needs, face to face, personally tailored and includes: home visits,
Cost
Included
devices, interventional pain management and hip and knee replacement procedures in all HMO markets and most
of our PPO markets. Our program aims to manage costs through prospective medical review and to encourage
network utilization.
Aetna’s Enhanced Clinical Review program helps contain rapidly rising costs while enabling members to Included
access care using evidence-based guidelines. Our outpatient precertification process includes high-tech
radiology procedures, diagnostic cardiology, facility-based sleep studies and cardiac rhythm implant
Enhanced Clinical Review Cost
Obstetrically trained nurses run our maternity program which aims to improve outcomes, reduce neonatal
services and costs and lower the high cost of care associated with complications.
babies at risk, one individual at a time. After a member completes a pregnancy risk survey by phone or through
our secure member website, she enrolls in the program and participates until after her baby is born. We provide
a personalized, supportive experience for all expectant mothers.
Aetna Maternity Program Cost
Our Aetna maternity program identifies pregnant members with conditions that put them and their Included
Programs and Services FI06/20/2019
#Proprietary
City Of Southlake
Programs and Services - Fully Insured Funding Effective Date: October 01, 2019
• Access ID card information
Our Servicing Framework puts the member first in every decision and promotes a culture of individual
accountability, trust, ownership and empowerment. Benefits include: Issues resolved faster, the first time. Our
Customer Service Representatives (CSRs) use lifelines that give them real-time access to support areas.
Technology - CSRs will educate and guide members on the benefits of Aetna's digital tools and programs.
Making it right - CSRs are empowered to make claim decisions in certain situations, while giving them guidance
on how to make the best use of their plan benefits.
Wellness Programs and Services
Allowances
wellness related programs or activities that are designed to promote the health and well being of plan
participants, or to educate the participants about healthy lifestyles and choices.
made once the expenses are incurred and invoice(s) are provided.
Invoices must be submitted to us within 60 days following the close of the plan year. Expenses must be for
the period.
Our preferred method of payment of wellness-related expenses is directly to the vendor. Payment will be
wellness services procured by the Plan Sponsor from third party vendors to pay for wellness-related
expense such as wellness fairs, biometric screenings and on-site flu vaccinations incurred during the
October 01, 2019 to September 30, 2020 plan year. These funds will be available as of the effective date of
Annual Wellness Allowance Cost
We are including a wellness allowance of up to $15,000 that may be used towards reasonable Included
completing the health assessment and one online health coaching program. Please refer to the Aetna
Healthy Commitments℠ Packages section included within this proposal.
Our offer includes the Enhanced Wellness Package, which includes all of the Core offerings (a health Included
assessment and online health coaching programs, discount programs, 24/7 Nurseline), plus onsite
biometric screenings, our year-long Aetna Get Active℠ fitness and nutrition challenges, incentives for
Aetna Healthy Commitments℠ Program Cost
24-hour nurse 1-800 support line – Members can call anytime and talk to a registered nurse for answers to health related Included
questions. They can also receive helpful videos via e-mail from an IHL Nurse. The videos are from the Healthwise video
library on hundreds of topics.
24/7 Nurse Line - Informed Health® Line Cost
Enhanced Customer Servicing Framework Cost
Included
• View coverage and benefits
• Email member services
• Find a doctor, dentist, hospital or urgent care facility
• View a map of the office location and call the office with the tap of a finger
• Estimate costs of care
• Manage prescriptions
• Search claims
• View health history
• Participate in online wellness programs
• Find a doctor
Our free app provides on-the-go capabilities and lets members and their families care for their health easily and
simply, from anywhere. We even offer fingerprint login capabilities. With the Mobile app, members can:
• Access personal health benefits
• Review claims status and details
• Compare provider costs and read reviews
• View health history
• Access wellness discounts
• Take health assessment
Our simple to use, intuitive, on-the-go member website, is an online resource for personalized health and
financial information where members can:
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Pharmacy Programs
Reporting
Consultation and reporting can be done on an as needed basis. Contact your Account Executive for more
information.
Behavioral Health
The AbleTo program makes it easy for our members to get the behavioral health help they need — before it can Included
complicate the health conditions they are already dealing with. We identify members with specific conditions or
life events that could benefit from behavioral health support. Members are then invited to join one of the
(there is a minimum monthly charge of $150).
Able To Network - subject to member cost share Cost
COBRA Services COST
Our rates exclude COBRA direct billing. If this service is elected, additional charges will be billed as Not
incurred. Please contact your account executive or account manager for a detailed Cobra proposal.Included
Information AdvantageTM.
We produce standardized reports based on Underwriting’s release policy for full-risk, experienced-rated
customers They are available through your account representative on a bi-annual basis of 100-199
covered employees and on a monthly bases for at least 200 covered employees through Aetna Health
refine how they look at the data with options such as time period, products, age, gender, region, clinical,
geographic and provider specific detail.
comparisons.
Each module can be drilled down into more detailed reporting and graphs allow users to group and
high-cost claimants, network savings and membership. These topics, called modules, are produced at the
customer level by funding arrangement and product type on an incurred basis with a two-month claim lag.
The modules offer a high-level view of the current data as well as book of business and prior year
plan decisions more quickly and confidently using focused, experience-driven data.
Interactive data analysis can be performed on topics such as key measures, components of medical trend,
Utilization Management Reporting Cost
Aetna Health Information AdvantageTM (AHIA) gets you the important plan performance information you Included
need, when you need it. It’s a rapid and flexible decision support tool that helps you make benefits and
Please note that this is optional on the Premier Plus formulary. We can also offer you our Aetna Rx Step
program that gives you the ability to customize your benefits approach. You’re able to elect all of the 13
key drug classes, or just choose the classes you want.
that our system will allow a claim for a specific drug to be processed, without intervention, if a member’s
claim history indicates that the predefined criteria have already been met.
Through our step therapy program, members must try one or more therapeutically equivalent prerequisite Included
drugs before a step therapy drug will be covered. One of the benefits of Aetna’s step therapy program is
coinsurance. If the physician indicates dispense as written(DAW) on the prescription, the member only pays the copay
amount. We strongly encourage plan sponsors to implement Choose Generics for considerable cost savings.
Step Therapy Cost
Choose Generics with Dispense As Written Override Cost
Your members get your best coverage when they use generics. When a drug has a generic equivalent, but a brand drug is Included
filled, members will pay the difference in cost between the generic and brand drug in addition to the required copay or
assume the funding of any wellness budget is either at the request of your Plan Administrator acting in
their fiduciary capacity to your Plan or for the exclusive benefit of your Plan.
allowance or other payments from us that offset or reimburse expenses that would otherwise be paid from
plan assets, should consult with their ERISA counsel to determine if such allowance must be credited to
plan assets, and for additional counsel regarding the accounting for reporting of such payments. We
costs incurred as a result of contracting with Aetna for benefits plan administration services, shall be
paid in accordance with applicable law. Plan sponsors are advised to determine appropriate accounting
for these payments with their own counsel or accountant. Any plan sponsor receiving a wellness
Any expenses beyond the Wellness Allowance are the responsibility of the customer. Any balance of this
allowance fund remaining at the end of the policy year will be forfeited. Any amounts ("Wellness
allowance") paid by Aetna to a plan sponsor to offset or reimburse such plan sponsor for any expense or
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Programs and Services - Fully Insured Funding Effective Date: October 01, 2019
AbleTo programs. Each program includes eight weeks of personal professional support through web-based video
conferencing or by telephone.
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Aetna Healthy Commitments℠ - Enhanced Package Effective Date: October 01, 2019
Wellness Programs Included to Help Members Stay Healthy and Improve Productivity
Onsite Biometric Screenings
We work with Quest Diagnostics for onsite health screenings that help your employees lower their risk
for health concerns. Quest offers unique services to fit your needs and the needs of your employees.
• Provides finger stick or venipuncture options, as well as fasting or non-fasting screenings
• Specializes in metabolic syndrome screenings and can provide customizable reporting
• Screenings available on-site and at patient service centers. Or, employees can submit physician forms or home kits.
• Offers a convenient, online scheduling system
• Requires 30 participants for finger stick screenings and 20 participants for venipuncture screenings
• Program Participation Minimum: A program participation fee of $600 will be charged for any program with less than 100
participants. This will be waived only if participation reaches or exceeds that number.
• Adaptive Technology
• Gaming Mechanics
• Proven behavior science methodology
Advocacy & Outreach Programs
24/7 Nurse Line - Informed Health® Line
While only your doctor can diagnose, prescribe or give medical advice, the Informed Health Line nurses can provide
information on more than 5,000 health topics. Contact your doctor first with any questions or concerns regarding your health
care needs. Informed Health Line nurses do not diagnose, prescribe or give members medical advice.
Member Wellness Message Program
Electronic communications for employees that address general health and wellness topics, available in English and Spanish.
Neighborhood Well-being Services
Provides members easy access to face-to-face lifestyle and preventive coaching support in their neighborhood CVS
MinuteClinics.
Communications Campaigns and Toolkits
preferences. Journeys are developed to maximize engagement and positive outcomes through use of:
Available programs include: Be Tobacco Free, Blood Pressure in Check, Diabetes Life, Eat Healthier, Get Active, Healthy Back,
Heart Healthy Cholesterol, Living Well with Asthma, Sleep Well, Stress Less, Weigh Less, and Health In A Hurry.
Our Informed Health® Line provides members with telephone and e-mail access to experienced registered nurses to help them
make informed health care decisions. Nurses are available through a toll-free telephone number 24 hours a day, 7 days a week.
one Online Health Coaching Program Journey.
Online Wellness Programs
Our online health coaching programs called Journeys®, make engagement simple, and use choice architecture – a powerful
technique derived from behavioral economics. Participants choose a Direction and then answer a few questions to help
personalize their Journey experience. Your subscribers will embark on a Journey that is tailored to their unique needs and
Incentives
Plan sponsors can add an option whereby subscribers and their spouses can each earn a $50 gift card after completing both
the Health Assessment and a minimum of one Online Health Coaching Program Journey.
Subscribers and their spouses can each earn a $50 gift card after completing both the Health Assessment and a minimum of
Health Assessment (Supported by Incentives)
Simple Steps To A Healthier Life®
Simple Steps To A Healthier Life® - Our online, personalized health and wellness program that includes a health assessment and
online health coaching programs. Based on information gathered in the health assessment, the participant receives a
personalized HealthMap, containing online coaching program recommendations to help them achieve and maintain good
health.
City Of Southlake
When it comes to wellness, our competitive advantage is that we offer more than 70 health and wellness programs, resources
and tools that help members make better lifestyle choices to stay productive.
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City Of Southlake
Fitness Challenge with Social Networking
Get Active℠
exclusions and limitations.
exclusions and limitations.
change.
For information about Aetna plans, refer to:
GR-29/GR-29N.
Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company and/or Aetna Life Insurance Company
Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full
cost of the discounted services. Information is believed to be accurate as of the production date; however, it is subject to
www.aetna.com
Policy forms issued in OK include: HMO/OK COC-5 09/07, HMO/OK GA-3 11/01, HMO OK POS RIDER 08/07, GR-23 and/or
Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc., Aetna Health of California
This material is for information only. Health information programs provide general health information and are not a substitute
for diagnosis or treatment by a physician or other health care professional. Health benefits and health insurance plans contain
Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and
conditions of coverage. Plan features and availability may vary by location and are subject to exclusions, limitations and
conditions of coverage. Plan features and availability may vary by location and are subject to change.
for diagnosis or treatment by a physician or other health care professional. Health benefits and health insurance plans contain
Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and
conditions of coverage. Plan features and availability may vary by location and are subject to change. Discount programs
provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted
services. Information is believed to be accurate as of the production date; however, it is subject to change.
For information about Aetna plans, refer to:www.aetna.com
Aetna Discount Programs
Our discount program helps members save money on a wide variety of products and services for themselves and their family.
Members can save on gym memberships, weight loss programs, eyeglasses, LASIK laser eye surgery, massage therapy and
much more!
This material is for information only. Health information programs provide general health information and are not a substitute
Get Active℠ is an online social network and health challenge platform for your employees. It offers interactive, seasonal
challenges to keep people moving and motivated throughout the year. Our team-based curriculum encourages healthy
behaviors such as increased physical activity, nutritious eating, weight loss and improved mental well-being.
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Caveats - Fully Insured Funding Effective Date: October 01, 2019
Assumptions
Prospective Quoting
The quoted insured medical rates are offered on a prospectively rated basis. No policy year accounting balance will be
calculated for these coverages.
Billing and Payment of Premium
Amount due is payable on the first day of the month covered by the invoice. If the amount due is not paid in full within 30
days, we reserve the right to terminate the contract and/or assess late premium payment charges.
Claim Fiduciary
Aetna will be the ERISA claim fiduciary for medical coverages. As claim fiduciary, Aetna
will be responsible for final claim determination and the legal defense of disputed benefit payments for medical.
Producer Service Fee
•The quote includes a Producer Service Fee of 4.2% of the Total Amount Due as determined between the Plan
Sponsor and Producer and memorialized in the Billing and Collection Agreement.
•The Producer Service Fee is negotiated directly between Plan Sponsor and Producer for services provided in
connection with the Group Medical benefit plan. Producer Service Fee is not a component of the premium but is
included in the Total Amount Due.
•The Producer Service Fee will be removed from the Total Amount Due if a Plan Sponsor and Producer do not
agree on a service fee amount and sign a Billing and Collection Agreement.
•The Plan Sponsor is not required to use a Producer to purchase insurance and may purchase a policy directly
from our company.
•The Plan Sponsor selects, retains, and contracts with the Producer on its own accord.
•The Plan Sponsor voluntarily chooses to pass the fee or commission through the issuer and is not required to do
so by our company. The Plan Sponsor may also elect to pay the fees or commissions directly to the Producer.
Contract Period
Our policies provide for automatic renewal upon the completion of each contract period unless either party invokes the
termination provision requiring 31 days advance written notice of termination to the other party. This provision may be in-
voked at any time during the continuance of the contract (that is, not just limited to termination occurring on the renewal date).
Contributions
We standardly require that the employer contribute 75% of the employee cost, or 50% of the total employee
and dependent cost. Employer contributions may not favor other medical plans over that of the Aetna plans. Our
plan will have neutral to favorable employer contributions after adjusting for plan design, compared to other medical
plans, including consumer directed plans (HRA and/or H.S.A. models). In option situations, employer contributions
must not disadvantage our offering.
Eligibility
Eligibility applies to:
•Permanent full-time employees working 25 hours or more per week, on a regularly scheduled basis.
•Eligible dependents include an employee's spouse, domestic partner, and children up to the limiting age of the
plan or as mandated by legislative requirement.
•Individuals cannot be covered as an employee and dependent under the same plan.
•Children eligible for coverage through both parents cannot be covered by both under the same plan.
Financial Condition
Plan Sponsor is a legitimate business and meets underwriting approval for acceptable financial strength. We reserve the
right to request additional supporting information in order to evaluate financial status.
Mandates
Benefit provisions are subject to state, local, and federal mandates. Future mandates will be incorporated in the plan(s) as of
the date required by law and may require rate adjustments.
Patient Management Center
Patient Management services for the plan sponsor will be administered by our regional Patient Management Center.
Plan Design
Total Replacement
We will be the sole carrier for the quoted lines of coverage. In the event alternative carriers or
Minimum Essential Coverage plans are to be offered, we reserve the right to reassess our rates.
Underlying Plan
Our quoted rating assumes that there are no underlying plans in effect that will either partially or completely subsidize any
member cost sharing including but not limited to co-pays, deductibles, and/or coinsurance balances. We reserve the right
to change the quoted rating or decline coverage if we have not been notified of the existence of an underlying plan.
Network Re-Contracting
In addition to standard fee-for-services rates, contracted rates with network providers may also be based on case and/or
per diem rates and in some circumstances, include risk-adjustment calculations, quality incentives, pay-for-performance and
This renewal is based on the current benefit plan designs, plus any noted deviations. Our standard provisions, contract wording and claim settlement
practices will apply for items not specifically outlined.
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Caveats - Fully Insured Funding Effective Date: October 01, 2019
other incentive and adjustment mechanisms. These mechanisms may include payments to organizations that may refer to
themselves as accountable care organizations (“ACOs”) and patient-centered medical homes (“PCMHs”), in the form of
accountable care payments (ACP) and incentive arrangements based on clinical performance and cost-effectiveness. The
ACP amount is based upon an assessment for each member who is already accessing providers in an ACO, and is
assessed retrospectively on a quarterly basis and collected through established claim wire. Each ACO will have a different
ACP based on the clinical efficiencies targeted and network negotiations. The ACP assists the ACO in funding transformation
of the health care system to improve quality, reduce costs and enhance the patient experience by:
• Identifying and engaging patients at risk for health crises sooner through more data-sharing
• Increasing patient engagement in best-in-class care management programs through doctor-driven outreach
• Delivering better health outcomes through increased collaboration between the health plan and ACO providers
We reserve the right to revise the premium, modify the terms of the offer, or terminate if:
Member/Subscriber Ratio
The enrolled member to subscriber ratio increases or decreases by more than 10% from the 2.11 ratio assumed in this quote.
Enrollment
The actual enrollment in total or by plan changes by more than 10% compared with what was proposed.
The plan sponsor offers coverage to employee previously not covered under the plan without prior notification.
(Change in census is based on additions and subtractions - a 60 life group who adds 3 people and takes away 3 others has a 6
person change in census even though they stay at 60 lives.)
Participation and Contribution Rules
Under Affordable Care Act (ACA) and state insurance regulations, a group health insurance policy may be non-renewed for
certain reasons. We reserve the right to non-renew for failure to comply with certain requirements such as participation
and/or contribuƟon rules.
Contract Provisions
The final benefit provisions, account structure, claim payment requirements or services change from those proposed.
Covered Lives, Demographics
A 5.0% percent change in the demographics and/or geographic mix of the enrolled group in aggregate or in any site with at
least 100 enrolled subscribers. A 10 percent change in the total number of subscribers enrolled in each individual product
or in aggregate, including the impact of new or terminating locations and/or groups.
Quoted Benefits
A material change in the plan of benefits offered, or a change in claim payment requirements or procedures, or a change in
state premium taxes or assessments, or any other changes affecting the manner or cost of providing coverage that is
required because of legislative or regulatory action.
Additional
Point of Service Rebates
This proposal may include point of service rebates (“POS Rebates”) favorable to, and shared with, eligible subscribers
and dependents. However, Aetna reserves the right to make appropriate changes to the premium offered hereunder
in the event POS Rebates are discontinued, in whole or in part, on account of any material changes made to
(i) the laws, rules and/or regulations applicable to POS Rebates or
(ii) any material drug manufacturer rebate contracts providing the source for POS Rebates.
European Union: General Data Protection Regulations (GDPR)
Aetna International has implemented a framework to follow the General Data Protection Regulation (GDPR), which became
law in all European Union (EU) and European Economic Area (EEA) countries on May 25, 2018. This law gives people greater
protection over their personal data, with the potential for significant fines for privacy breaches. GDPR includes requirements
related to data collection, storage and usage among the companies and organizations that process personal data of
individuals in the European Union.
Our domestic plans are not in scope. To help support operational requirements of GDPR, members based in the EU and EEA
must be enrolled in Aetna International plans.
Medical EOBs
We make EOBs available through our secure Navigator website for subscribers who have registered to use Navigator and
for whom we have a valid email address. We send members an email when a new EOB is available. All other members
receive paper EOBs. If a member receiving EOBs electronically prefers paper EOBs, they can get them by telling us that is
their preference. Please note that unless required by state law we do not produce EOBs for claims when there is no
member liability.
Medical Disclosure Information
At the time of annual enrollment, your plan participants should be provided with the Medical Disclosure information related to
their plan of benefits. Go to our corporate website and enter the state followed by the word 'Disclosure' in the search field
Please provide the applicable Medical Disclosure document and any required Addendum to your plan participants. If you have
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Caveats - Fully Insured Funding Effective Date: October 01, 2019
any questions, please contact your broker or account management team.
Health Care Reform Caveats
Healthcare Reform Disclosure
This renewal is intended to be compliant with health care reform.
Under the federal health care reform legislation, health plans existing prior to the enactment of the Affordable Care Act may
be "grandfathered" and not subject to some of the mandated benefits and reform provisions. Changes in your benefit design
as well as your contribution strategy may affect grandfathering. Plan sponsors are required to notify us if their contribution
rate changes for a grandfathered plan at any point during the plan year.
This renewal offer assumes your plan is not grandfathered.
As a non-grandfathered plan, the plan will include Preventive care as defined by regulation without cost sharing on In Net-
work services.
Certain employers and organizations may be exempt from contraceptive services coverage requirements, and
choose an optional accommodation. If you qualify and want to be exempt from including ACA contraceptive services
benefits in your policy, please work with your Account Manager/Account Executive to provide the required documentation to
us so that we can administer accordingly. We have the right to treat insured plans as subject to the ACA contraceptive
services coverage requirements without an executed certification document. Applicable state laws requiring coverage of or
related to contraceptive services benefits still may apply.
Except for specific and limited scenarios described as transitional rules in the health care reform legislation, if a plan's grand-
fathered status has been lost, it cannot be regained. If, after reviewing the grandfathering rules with your benefit consultant
or counsel, your determine that your coverage could be or is grandfathered, and you want to retain grandfathered status,
please contact us for further instructions.
We reserve the right to treat an insured plan as non-grandfathered.
Retiree Only Plan Status Certification
Guidance issued by the Internal Revenue Service (“IRS”), Department of Labor (“DOL”), and Department of Health and
Human Services (“HHS”) has indicated that “retiree only” plans are exempt from the benefit mandates under ACA including
Medical Loss Ratio (“MLR”) and rebate requirements for insured plans (Retiree only plans are subject to certain ACA fees
and assessments). In order to demonstrate the establishment of a retiree only plan, a plan should maintain, separately from
the plan for current (i.e., active) employees, a separate plan document and Summary Plan Description (SPD) and file a
separate Form 5500. If you have a retiree only plan, and want to be considered exempt, please provide the required
documentation to us. We have the right to treat insured plans as subject to ACA without an executed certification document.
Affordable Care Act – fees and assessments
The Affordable Care Act (ACA) imposed several fees/assessments. Still applicable in 2018 are the Health Insurance and
the Patient-Centered Outcomes Research Institute Fee.
•Health Insurance Providers Fee (HIF) is a recurring, annual, industry fee assessed based on each insurer’s
share of the fully insured market, as determined by the IRS. A total of $14.3 billion will be collected across the
industry for 2018. The total assessment will increase each year thereafter, at the rate of industry premium
growth thereafter. The Spending Bill, signed into law on 1/22/18 included the suspension of HIF
for calendar year 2019. HIF is reinstated for calendar year 2020.
•Patient-Centered Outcomes Research Institute Fee (PCORI)–This fee is in effect for plans or policy year ending
after September 30, 2012, and before October 1, 2019.
This rate quote includes, as applicable, an estimated proportionate allocation of expense associated with the Health
Insurance Provider Fee and the Patient-Centered Outcomes Research Institute Fee. We reserve the right to modify these
rates, or otherwise recoup such fees, based on future regulatory guidance, subsequent state regulatory approval, or if
estimates are materially insufficient.
Waiting Period Requirement
When renewing your plan(s) with us, you represent that:
• You will give us effective dates for your employees and their dependents that take into account all state and
federal eligibility conditions and waiting period requirements, including a reasonable and bona fide orientation
period.
• If this information changes, you will inform us immediately.
Summaries of Benefits and Coverage (SBC)
The SBC must include statements about whether the plan or coverage provides minimum essential coverage (MEC)
This renewal includes the women's preventive care coverage requirements, e.g., coverage for contraceptive methods and counseling, breastfeeding
support and equipment, and prenatal care.
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City Of Southlake
Caveats - Fully Insured Funding Effective Date: October 01, 2019
and if the coverage meets minimum value (MV) requirements.
Under the Affordable Care Act (ACA), minimum value and minimum essential coverage determinations are associated with
the employer shared responsibility provisions. We will review the minimum value standard for each plan based on the MV
calculator criteria provided by the Department of Health and Human Services (HHS) and will indicate within the SBC whether
the plan meets or does not meet the MV standard based on this review. We do not provide legal or tax advice, and
recommend that plan sponsors consult with their own legal and tax counselors when reviewing MEC and MV
determinations. We have no responsibility or liability regarding the minimum value or minimum essential coverage
evaluation, regardless of the role we may have played in reviewing/producing the SBC documents. To the extent you disagree
with our evaluation, we will make changes to reflect your determination, as you are responsible for the final determination of
these SBC elements.
Employer Reporting Requirements
Under Internal Revenue Code (IRC) Section 6055 health insurance issuers, certain employers, government agencies and
other entities that provide Minimum Essential Coverage (MEC) to individuals must report to the IRS information about the type
and period of coverage and furnish related statements to covered individuals. This information is used by the IRS to
administer the individual shared responsibility provision and by individuals to show compliance with the individual shared
responsibility provision.
For insured group health plans, the reporting obligation under Section 6055 is our responsibility. We will report the required
information to the IRS about the type and period of coverage provided to each individual member enrolled in our insured
plans, and will furnish the required statements to subscribers.
We must report the entire Social Security numbers (SSN) to the IRS for each sub-
scriber and dependent in order to complete our required reporting. However, the final rules allow the use of truncated social
security numbers on statements furnished to individuals (for example, give only the last four digits of the SSN). If we don’t
receive the SSN through the employer, the law requires we reach out to each subscriber up to three separate times to
request the information.
IRC Section 6056 requires applicable large employers (those having employed an average of 50 or more full-time employees
during the preceding calendar year) to report to the IRS information about the health care coverage they have offered and
also furnish applicable statements to employees. The purpose is to allow the IRS to enforce the employer responsibility
provisions.
To satisfy the 6056 employer reporting requirements, an applicable large employer must file the required returns with the IRS
by no later than February 28 of the year following coverage (if filing on paper) or March 31 (if filing electronically), and
furnish a statement to all full-time employees by January 31st of the year following the calendar year to which the return
relates.
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The Federal Mental Health Parity and Addiction Equity Act Effective Date: October 01, 2019
The Federal Mental Health Parity and Addiction Equity Act (MHPAEA) requires parity in coverage for mental health and substance abuse services compared
to medical and surgical services. The law allows outpatient benefits to be sub-classified between "office visits” and "all other" outpatient services.
Beginning on 1/1/18, or your next renewal date, we are changing your benefits separating Outpatient Mental health/Substance Abuse into two new benefit
categories: BH Office Visit and BH All Other.
•"BH Office Visit " includes services where members will interact with a provider in an office setting for treatment
•"BH All other" includes services where members will have some other interaction with providers in obtaining care – such as technological intervention or
where the service is traditionally delivered outside an office setting, like in the home
Beginning January 1, 2018, the following Behavioral Health services will be classified as behavioral health outpatient “all other” for purposes of Federal
Mental Health Parity law:
•Partial hospitalization programs (PHP)
•Intensive outpatient programs (IOP)
•Applied behavior analysis (ABA) for the treatment of autism spectrum disorder
•Home health care
•Transcranial magnetic stimulation
•Electroconvulsive therapy (ECT)
•Vagus nerve stimulation (normally an excluded benefit)
•Outpatient monitoring of injectable therapy
•Psychological testing
•Neuropsychological testing
•Medical treatment for withdrawal symptoms
•Outpatient detoxification
•Ambulatory detoxification
•23-hour observation
In an effort to comply with the new law, we are also revising several medical, mental health and substance use disorder
benefits cost share. In order for your plan to pass the ‘substantially all” and “predominate” cost share testing required by MHPAEA, the following medical
benefits cost share may change with your renewal:
•Lab
•X-ray noncomplex and X-ray complex
•Outpatient Surgery Freestanding
•Outpatient Surgery Hospital
•Medical Injection in an Office Visit
•Home Health
•Outpatient Hospice
In addition, the behavioral Health All Other benefit will have a cost share that is equal to or better than the above medical benefits.
City Of Southlake
Federal Mental Health Parity06/20/2019
#Proprietary
PayFlex Account Fees Effective Date: October 01, 2019
N/A
N/A
$4.25
$22.50
$5.00
$150.00
Implementation Fee
Less than 999 Eligibles:
999+ Eligibles:
$500.00
N/A
$500.00
N/A
$0.80
$0.70
$0.60
$150.00
Included
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Comprehensive plan sponsor website for reports with On-Demand Feature, documents and
member information
Account Management support
Updates on legislative changes
Monthly Statements - Online
PayFlex Mobile Application
Single Sign On (SSO) to standard PayFlex member website
Medicare Notices
Notices of delivery via First Class mail (including Proof of Mailing for Initial Rights Notices and
Qualifying Event Notices)
Severance package management
Member service through IVR, live agents, click to chat, and email
Website member service for current account status, payments and mailed documents
Member communication option via email with eNotify™ and website alert notifications
COBRA elections and terminations
Premium collection and distribution
Eligibility updates to carriers
Disability extensions
Conversion Rights Notices
Notices of Unavailability
Fee includes:
- COBRA Administration
- New Hire COBRA/HIPAA Initial Rights Notice
- Qualifying Event Notification
- COBRA Member Termination Notice
20-499 Employees
500-999 Employees
1000+ Employees
Minimum Monthly Billing - Per Employer
Product Feature
PayFlex provides many standard services with COBRA administration such as:
Takeover of pending and enrolled members
Qualifying Event Notices
Qualified Event Notification (per event)
COBRA Member Termination Notice (per notice)
Minimum Monthly Billing - Per Employer
COBRA Per Eligible Employee Per Month (PEPM)
Annual Fee
Less than 999 Eligibles:
999+ Eligibles
COBRA Subscriber Fee
City Of Southlake
COBRA Per Event (Available for groups with 500+ eligibles)
Implementation Fee
Annual Fee
New Hire COBRA/HIPAA General Rights Notice and Renotification (per notice)
#Proprietary
PayFlex Account Fees Effective Date: October 01, 2019
City Of Southlake
COBRA Per Event (Available for groups with 500+ eligibles)Fee
$15.00 per package
plus postage*
$0.60 per page
plus postage
$5.00
$5.00
$150.00 per hour
$10.00
$3.00
$3.00
$10.00
$50.00 per carrier per
month
$50.00 per occurrence
of any client funding
ACH pull that is rejected.
$150.00 per hour
Statement of Work
required.
Customized Reporting and Web Development
Per Event:
By the 5th working day of each month, PayFlex will provide a bill for all administration from the prior month. Reports detailing the prior month’s activity
will also be provided for your records.
PayFlex shall retain the 2% administrative fee on the total premium administered for COBRA members.
Fee shall remain unchanged during the initial thirty-six (36) months of the term of the Agreement; thereafter fees are subject to change every twelve
(12) months and shall not exceed a three (3) percent net increase per year for the Initial Term of the Agreement.
Pricing quotations expire 90 days after the initial proposal publication date.
PEPM:
Manual Notification Form Processing (per form)
Non-Commencement Notice (per notice)
Late Payment Notice (per notice)
Optional Government Mandated Notice (per notice)
Premium Disbursement to carriers (No fee for remittance to Aetna)
Rejected/NSF Client Funding ACH Transactions
COBRA Optional Services - Per Event/Per Eligible Employee Per Month (PEPM)
Annual Open Enrollment Services
(*Per package with a $300.00 minimum plus postage, available after PayFlex has been providing administration for a
minimum of 90 days.)
Summary of Benefits and Coverage Form
(Only offered when included with Open Enrollment Services.)
Annual Open-Enrollment Election Form Processing (per form)
(Service offered if the plan sponsor administers the open-enrollment but wants the Open Enrollment form returned to
PayFlex for processing.)
Custom Mailings (Non-Standard Notices) (per notice)
Custom Mailings (Set Up Fee)
#Proprietary
PayFlex Account Fees Effective Date: October 01, 2019
City Of Southlake
COBRA Per Event (Available for groups with 500+ eligibles)
$500.00
N/A
$500.00
N/A
$5.60
$5.35
$4.85
$4.55
$150.00
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Member service through IVR, live agents, click to chat, and email
Web-based member service for current account status, payments, system-generated documents
Member communication options via email with eNotify™ and website alert notifications
Comprehensive plan sponsor website for reports with On-Demand Feature, documents and
member information
Member service through IVR, live agents, click to chat, and email
Website member service for current account status, payments and mailed documents
PayFlex provides many standard services with Direct Billing administration such as:
Billing Services for:
o Retirees
o Leave of Absence
o Layoffs
o LTD Members
Takeover of existing members
Premium collection and distribution
Flexible grace period time periods based on plan sponsor requirements
Eligibility updates to carriers
Implementation Fee
Less than 999 Eligibles:
999+ Eligibles:
Annual Fee
Less than 999 Eligibles:
999+ Eligibles:
Monthly Administration Fee Per Active Member (PMPM)
2 - 999 Per Member Per Month
1000 - 2499 Per Member Per Month
2500 - 4999 Per Member Per Month
5000+ Per Member Per Month
Minimum Monthly Billing - Per Employer
Product Feature Included
By the 5th working day of each month, PayFlex will provide a bill for all administration from the prior month. Reports detailing the prior month’s activity
will also be provided for your records. Prior to issuing the monthly invoice for the COBRA administration fees, PayFlex will provide the plan sponsor with
an email as a reminder to update the COBRA eligible employee count on the plan sponsor website that will be used for the current month’s Monthly
Fee Per COBRA-Eligible fee. The plan sponsor agrees to update this count prior to the end of the current billing month. If PayFlex is not provided an
updated number of COBRA eligible employees by the end of the current billing month, the plan sponsor agrees to pay the fee based on the count used
the previous month. A COBRA eligible employee is defined as an active employee who is enrolled in one or more COBRA eligible plans (medical, dental,
vision, FSA, EAP, etc.). If an employee is enrolled in more than one plan, the employee is only counted once.
PayFlex shall retain the 2% administrative fee on the total premium administered for COBRA members.
Note: The above fees are based on approximately XXXXX benefit covered employees with approximately XXX% annual turnover.
Should there be a variance in turnover exceeding +/- 10%; the fees outlined above are subject to negotiation.
Services included in the PEPM fee include; COBRA Administration, New Hire COBRA / HIPAA General Rights Notice, Qualifying Event Notification, and
COBRA Member Termination Notice.
Fee shall remain unchanged during the initial thirty-six (36) months of the term of the Agreement; thereafter fees are subject to change every twelve
(12) months and shall not exceed a three (3) percent net increase per year for the Initial Term of the Agreement.
Pricing quotations expire 90 days after the initial proposal publication date.
Direct Billing
#Proprietary
PayFlex Account Fees Effective Date: October 01, 2019
City Of Southlake
COBRA Per Event (Available for groups with 500+ eligibles)√
√
√
√
Fee
$15.00 per package
plus postage*
$0.60 per page
plus postage
$5.00
$5.00
$150.00 per hour
$10.00
$3.00
$5.00
$50.00 per carrier per
month
$50.00 per occurrence
of any client funding
ACH pull that is rejected.
$150.00 per hour
Statement of Work
required.
Medicare Part D Certificate (per letter)
Premium Dispursement to carriers (No fee for remittance to Aetna)
Rejected/NSF Client Funding ACH Transactions
Customized Reporting and Web Development
Summary of Benefits and Coverage Form
(Only offered when included with Open Enrollment Services)
Annual Open-Enrollment Election Form Processing (per form)
(Service offered if the plan sponsor administers the open-enrollment but wants the Open Enrollment form returned to
PayFlex for processing.)
Custom Mailings (Non-standard notices) (per notice)
Custom Mailing (Set up fee)
Manual Notification Form Processing (per form)
Late Payment Notice (per notice)
Account Management support
Monthly Statements - Online
PayFlex Mobile Application
Single Sign On (SSO) to standard PayFlex member website
Direct Billing Optional Services
Annual Open Enrollment Services
(*Per package with a $300 minimum + postage, available after PayFlex has been providing administration for a minimum of
90 days.)
#Proprietary
City of Southlake
by Lifetime Benefits
October 1, 2019 through September 30, 2020
Presented to
An Aetna Proposal
Effective Date: October 1, 2019
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and guide them to their best dental health.
Awards and recognitions
As we transform the health care experience, we’re honored to be recognized for our work.
Click here to learn more about Aetna’s awards and recognitions.
we’ll focus on what’s important—their needs and the needs of their families. We’ll personalize their experience
Affordable plan options provide the coverage and protection members want. Tools and information drive
engagement and help members make the most of their benefits.
Large provider networks offer greater access to care
National Dental Preferred Provider Organization (DPPO) network currently has more than 313,000 dental
providers.
Dental Maintenance Organization (DMO) is one of the largest in the country with over 114,000 dentists.
Our dental program focuses on improving overall health outcomes. As we meet members on their journey,
Member empowerment
dental health goals.
Aetna Dental focuses on driving value through three key areas :
Tailored benefits
Targeted, local networks make it easier for members to access care and keep costs low. A variety of plan
options allow you to better manage cost, coverage and access.
Integrated care
Our care programs use dental health and primary care information to drive improved overall health outcomes.
journey. Aetna’s member outreach and education has helped change member behaviors, allowing them to reach
City of Southlake
Aetna’s Dental Value Story
At Aetna, we dedicate ourselves to help members reach their best health. As a trusted carrier for 13 million
dental members, Aetna is the largest integrated carrier in the business. We’re also one of the first to study
the benefits of dental-medical integration, which leads to better health outcomes for our members.
Improving overall health through better dental health
Dental health has a significant impact on emotional health. One’s overall happiness and confidence is often
impacted by the health of their teeth. Our dental program meets members where they are on their dental health
Page 2 6/5/2019
Effective Date: October 1, 2019
Contact Information
Account Executive:Thomas Lavelle Email:LavelleT1@aetna.com
Telephone Number:469-608-0044
Quote Assumptions
Effective Date:10/01/2019 Contract Period:12 Months
End Date:09/30/2020 Lives:316
Contract State:TX SIC Code:9111
Member/EE Ratio:2.07
Fully Insured Commissions
PPO 3.00%
DMO 3.00%
Health Insurer Fee Year 1:1.95%
Fully Insured Dental (Estimated) Health Insurer Fee Year 2*:2.60%
DMO Lives Monthly Rate PEPM Monthly Premium
EE 17 $14.75 $251
EE + Sp 5 $28.03 $140
EE + Ch(ren)2 $29.53 $59
Family 8 $45.72 $366
Total 32 $25.49 $816
Traditional Option 1 Lives Monthly Rate PEPM Monthly Premium
EE 136 $39.11 $5,319
EE + Sp 34 $78.23 $2,660
EE + Ch(ren)42 $87.02 $3,655
Family 72 $132.51 $9,541
Total 284 $74.56 $21,174
Total Monthly 280 $21,990
Total Policy Period $263,880
*The Patient Protection and Affordable Care Act imposes a Health Insurer Fee ( the “Fee”). The Fee became effective
on January 1, 2014. The Fee will be suspended for 2019, but reinstated starting in 2020. This rate quote includes,
where permitted, the estimated proportionate allocation of the Fee for the years where the Fee is applicable.
Rate Cap
For your renewal, we have offered a 2nd year rate cap where the maximum percentage increase in the premium rate
will be 3.9% for Dental DMO options and 5.8% for Dental PPO options, plus any
applicable increase associated with the Health Insurer Fee (see the Affordable Care Act (ACA) section in the dental
proposal on the caveats page) for the subsequent 12-month period. The rate cap is subject to the same terms and
conditions as stated under the Assumptions section on the caveats page of your proposal.
Middle Market Cross Sell Pricing Program
Dental participation must be over 40% for Cross Sale Discount to be applied to rates.
Dental rates are final and contingent upon the acceptance of the Aetna Medical Renewal.
City of Southlake
Proposed Rates/Fees
Page 3 6/5/2019
Our secure member website, is a powerful online tool that provides members health and benefits
information at their fingertips 24 hours a day, 7 days a week. In one, easy-to-use website, they can perform
a number of self-service functions related to their health benefits plan, and take advantage of a vast
amount of dental consumer health information.
We make it easy for Aetna Dental® members to access tools and resources that help them maximize their
benefits and become more active participants in their oral health. Our member website helps them to
learn about the cost of dental procedures, evaluate dental providers and schedule provider visits.
Aetna Dental® members can access all the tools and information they need to make the best decisions
about their dental health, including:
•Out-of-pocket cost estimates based on a member's plan, network and provider rates
•Provider search capacities by name, location, specialty or procedure that will also educate
members on the benefits of seeing an in-network provider should they search for someone
out-of-network
•A dashboard that provides an easy-to-use summary of benefits, claims and plan balances
•Provider profiles that contain:
-Ratings based on a provider's professional history, affordability, patient experience and
online reputation
-The number of visits to a provider by fellow employees
-Reviews written by patients of participating providers
-An online scheduling tool which allows individuals to schedule appointments with
participating providers
These improved tools help members reduce out-of-pocket costs, better manage their family's oral health
and more easily research and connect with in-network providers.
Additionally, claims activity and website use trigger communications to members throughout the plan
year, including:
•Care reminders that notify members when they are due for their dental check-up and cleaning
•Confirmations from providers for appointments scheduled online
•Post-appointment patient surveys to measure their satisfaction with the provider
We're always looking for new ways to empower individuals with the tools and information they need to
achieve their health ambitions. Our goal is to drive a better understanding of the cost of care, greater
in-network utilization and higher satisfaction amongst Aetna Dental® members.
Your employees can save on many health-related services including chiropractic and acupuncture
services as well as massage therapy and nutritional counseling. Order other healthy items like over the
counter vitamins, herbal and nutritional supplements.
City of Southlake
Aetna Programs and Services Effective Date: October 1, 2019
Aetna Member Website
Natural Products and Services
Page 4 6/5/2019
City of Southlake
Aetna Programs and Services Effective Date: October 1, 2019
Get discounts on gym memberships with GlobalFit. Save at over 10,000 gyms in the network. Choose
at-home weight-loss programs or work with a health coach with GlobalFit.
The Aetna VisionSM discounts helps you and your family save on many eye care products, including
eyeglasses, contact lenses, nonprescription sunglasses, LASIK surgery, contact lens solutions and other
eye care accessories.
Save on blood pressure monitors, pedometers, activity trackers and many other Omron® products.
Standard reports are produced quarterly at the customer level on an incurred claim basis, rolling 12
months and with a 2-month claim lag. Reports are available to customers with at least 100 dental
subscribers. The reports offer a view of the current year’s and the prior year’s data, illustrating utilization
and financial trends in a concise, graphical format.
Level A COST
Standard reports are produced quarterly at the customer level on an incurred claim basis, Included
for the most current rolling 12 months, and with a 2-month claim lag. Reports are available
to customers with at least 100 enrolled dental subscribers. The reports offer a view of the
current year's and the prior year's data, illustrating utilization and financial trends in a
concise, graphical format.
The Level A Dental Standard Report package includes the following exhibits: Key Statistics,
Trend Analysis by Dental Cost Category, Dental Provider Network Experience, Dental Cost
Sharing Analysis, Demographics for Dental Membership, Top 25 Services by Dollar Amount,
Summary by Package (ASC only)
Level B COST
Level B contains the same reports as Level A; however, Level B allows the user to easily run Included
variations on the Level A reports by selecting various time periods, account structure, time
periods, account structure, product combinations and incurred versus processed claim data
(available for self-funded customers only).
Ad Hoc COST
For customers with 100 or more enrolled subscribers, customized reports are also $200
available upon request from Aetna Integrated Informatics®. A business consultant will be per hour
assigned to respond to your tailored information and analytic needs. Charges and delivery
dates for customized or ad hoc reports will be quoted in advance. Availability of certain data
may be limited for our fully-insured customers.
Case with medical and dental (hours are shared between the coverages):
100 - 2,999 subscribers - 5 hrs free;
3,000 & over subscribers - 10 hrs free;
Standalone dental (regardless of size): 5 hours free
Aetna VisionSM Discounts
At Home Products
Reporting
GlobalFitTM
Page 5 6/5/2019
Caveats Effective Date: October 1, 2019
The proposed rates are illustrative and subject to change based upon underwriting review of the information
listed and requested below. Receipt of this information is required prior to release of final rates/approval.
Any of the information listed below, which has not been provided, may be required prior to final approval of a
sale.
Current
Current rates/fees and plan designs.
Renewal
Renewal rates/fees and plan designs.
Claims
Updated monthly claims on incumbent carrier letterhead on a rolling 12-month basis with corresponding
exposures up to 60 days prior to the effective date.
Demographics
Census data on incumbent carrier letterhead for all employees eligible for coverage, including: each
employee’s date of birth, insurance status, dependent coverage, gender, and home zip code. Census should
also identify whether each employee is active, COBRA, part-time, union, early retiree, retiree or waiver and the
plan/product in which the employee is currently enrolled. Additional information may be required if union
members, retirees or part-time workers are eligible.
Contribution Strategy/Participation
Non-contributory plans: The employer pays 100% of the cost of employee only coverage (100% participation
required)
Voluntary plans: The employer pays less than 50% of the cost of employee only coverage (30% participation
required)
Contributory plans: The employer pays at least 50% of the cost of employee only coverage (75% participation
required)
Eligibility
Permanent full-time employees work a minimum of 25 hours per week on a regularly
scheduled basis and that eligible dependents include an employee's spouse and unmarried children up to the
limiting age of the plan. Our proposal assumes no changes from current eligibility assumptions.
Total Replacement
Aetna will be the sole carrier for the quoted lines of coverage.
Mandates
Benefit provisions are subject to state, local, and federal mandates. Future mandates will be incorporated in
the plan(s) as of the date required by law and may require rate adjustments.
Dependents Eligibility
Spouse, children from birth to age 26.
SPD Modification
Our Service Fees (Premium for Fully Insured groups) include Aetna standard Summary Plan Description
language and any customization may require an additional cost.
Late Entrant Provision
An employee or dependent who does not enroll within 31 days of first becoming eligible (or during an
approved open enrollment period, or after a qualifying life event) is subject to the Late Entrant Provision. This
includes any employee or dependent who was previously eligible but didn't elect coverage when initially
eligible and enrolls during an employer's subsequent annual enrollment period. These members would have a
12-month waiting period for Basic & Major services. All diagnostic and preventive services are covered
regardless of whether they are classified as Type A Preventive or Type B Basic. Late Entrants also have a
24-month waiting period for Orthodontia.
City of Southlake
Documentation needed from current carrier(s)
Assumptions
Page 6 6/5/2019
Member/Employee Ratio
The enrolled member to employee ratio increases or decreases by more than 10% from the 2.07 ratio assumed
in this quote.
Enrollment
The actual enrollment in total or by plan changes by more than 10% compared with what was proposed.
The plan sponsor offers coverage to employee previously not covered under the plan without prior notification.
Information Accuracy/Demographics
The information provided is inaccurate and/or the demographics of the quoted group change resulting in +/-
5% premium difference.
Contract Provisions
The final benefit provisions, account structure, claim payment requirements or services change from those
proposed.
60 Day Provision
A decision is not reached within 60 days from the time the quote is released.
COBRA
The total number of COBRA enrollees exceeds 10.0% of the total enrolled group or the total number of COBRA
enrollees increases by more than 10.0 percentage points from what was assumed in this quote.
Retirees
The total number of Retiree enrollees exceeds 10.0% of the total enrolled group or the total number of Retiree
enrollees increases by more than 10.0 percentage points from what was assumed in this quote.
Industry
The nature of business and/or SIC code (9111) changes compared with what was assumed in setting the rates.
Multiline Discount
Our quoted fees reflect a credit adjustment for economies of scale pricing, assuming multiple product lines
will be awarded.
If actual lines of business awarded differs from our proposed package of benefits, Aetna reserves the right to
revise our quoted fees.
First Year Renewal
The first year renewal will be delivered 60-90 days prior to the anniversary date.
Premium Reduction
Aetna is offering a one month premium reduction of $21,990 or amount equal to one (1) month of premium,
whichever is less. This reduction would apply to a mutually agreed upon month in 2019 and would be included
as part of the final contract. Standard contract termination provisions apply and early termination will not impact
the amount of the reduction. Future renewals will be calculated based on the annualized premium before giving any
effect to the premium reduction. You may wish to consult with your legal advisers about any changes that you may
need to make in the administration of your plan as a result of this reduction consistent with your fiduciary
obligations such as making adjustments to participant contributions.
Producers (Brokers, Agents, Consultants):
Licensed and appointed producers may earn compensation in the form of a commission on the sale of this product.
The amount of compensation varies. It depends on a number of factors, including customer segment and the
products selected. Additional bonus programs may also apply. Please ask your broker for more information about
their compensation for this sale, including commission and any applicable bonus programs. The producer is
prohibited by law from altering the amount of compensation they get from us based in whole or in part on the sale.
Salaried Aetna Employees:
Salaried employees may be compensated for selling Aetna products. The amount of compensation varies. It depends
on a number of factors, including customer segment and products selected. Combining all factors, and excluding
limited-benefit plans, compensation for each product quoted averages less than 0.80% of the total first-year annual
premium. Our additional bonus programs may also apply. Neither Aetna nor the employee has material ownership
interests in the other. The employee may not alter the amount of their compensation.
Contact us at https://www.aetna.com/about-aetna-insurance/contact-us/forms/employer/transparency.html for
more information about the compensation eligible employees may receive, which is based in whole or in part on the
sale of an Aetna product or alternative options presented.
Additional Caveats
Producer Transparency
Aetna reserves the right to revise rates or withdraw the quotation if:
Page 7 6/5/2019
Employees in AZ, CA, GA, MA, MD, MO, NC, NJ and TX must either live or work within the approved DMO®
service area to be eligible to enroll in the DMO®.
Attention customers with Massachusetts residents: You should be aware that our network of preferred providers in
Massachusetts has providers mainly in the following counties: Barnstable, Berkshire, Bristol, Essex, Hampden,
Hampshire, Middlesex, Norfolk, Plymouth, Suffolk and Worcester. Members’ out of pocket expenses will be higher if
they do not see an in-network provider and, in some plans, benefits may not be available at all for out-of-network
providers.
Page 8 6/5/2019
We make EOBs available through our secure Navigator website for subscribers who have registered to use
Navigator and for whom we have a valid email address. We send members an email when a new EOB is available.
All other members receive paper EOBs. If a member receiving EOBs electronically prefers paper EOBs, they can get
them by telling us that is their preference.
Disclosure Statement
"Aetna" is the brand name used for products and services provided by one or more of the Aetna group of subsidiary
companies. DMO plans are underwritten by Aetna Life Insurance Company, except in the following states:
• Aetna Dental of California Inc.
• Maryland, Missouri, North Carolina, Texas: Aetna Dental Inc.
• New Jersey: Aetna Dental Inc. and Aetna Life Insurance Company.
"Aetna" is the brand name used for products and services provided by one or more of the Aetna group of subsidiary
companies. PPO/PDN and Indemnity plans are underwritten by Aetna Life Insurance Company.
Certain dental plans are available only for groups of a certain size in accordance with underwriting guidelines.
While this material is believed to be accurate as of the print date, it is subject to change.
For more specific information about the coverage details, including limitations, exclusions, and other plan
requirements, please contact an Aetna representative.
Aetna has various programs for compensating producers (agents, brokers and consultants). If you would like
information regarding compensation programs for which your producer is eligible, payments (if any) which Aetna
has made to your producer, or other material relationships your producer may have with Aetna, you may contact
your producer or your Aetna account representative. Information regarding Aetna's program compensating
producers is also available at www.Aetna.com.
Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician
or other health care professional. Not all health/dental services are covered. Aetna does not provide care or guarantee access to
dental services. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan
features and availability may vary by location and are subject to change.
EOB's
Affordable Care Act (ACA)
Policy forms issued in Oklahoma include: HMO/OK COC-4 09/02, HMO/OK GA-3 11/01, CHI/OK GP-3 02/02, CHI/OK INSCT-4 01/02,
GR-23, GR-29, GR-700-W, GR-96172 and/or GR-96173.
Page 9 6/5/2019
Aetna's Dental/Medical IntegrationSM Program Effective Date: October 1, 2019
Our Dental/Medical Integration competitive advantage lies in successfully affecting member behavior. Since
we have medical and dental claims data, we can put our knowledge to work for your members because we
have a complete picture of their claims history. We differentiate ourselves from the market because of how
we identify those members who should be concerned with their dental health and its impact to their overall
medical condition. At this time, Aetna defines at-risk members as those who are pregnant or have
cardiovascular disease or diabetes.
•Focusing on members who have not had a recent dental visit, the DMI member outreach program uses
multiple outreach methods proven to be successful in motivating at-risk members to seek care.
•Claim data is monitored to determine if the member sought care after initial contact. Follow- up outreach
is provided if the member does not seek care.
•One additional prophylaxis (cleaning visit)
•Scaling and root planing
•Full mouth debridement to enable comprehensive evaluations and diagnosis
•Periodontal maintenance
• Enroll in the enhanced benefit •Select a dentist •Get help with making a dentist appointment
*Exclusions and limitations may apply. Refer to your plan documents, available after enrollment, for details.
1Periodontal Disease and Systemic Health https://www.perio.org/consumer/other-diseases. Accessed October 2018
2“An examination of periodontal treatment and per member per month (PMPM) medical costs in an insured population” BMC Health Services Research 2006:103
Smart Aetna programs bring together dental and medical care
Educate at-risk members who may not be aware of how oral health can affect their specific medical conditions. Members of
dental and medical insurance plans from Aetna may get these added benefits, when you select the DMI program.
Aetna's Outreach Program
Enhanced Benefit* Programs Fully Cover Additional Services with NO deductible
For pregnant women, members with diabetes and coronary artery disease/cerebrovascular disease
Members will receive educational material and will be encouraged to call our Dental Service Center to:
City of Southlake
Put the bite on medical costs with an integrated dental/medical program.
Help reduce the risks of heart disease, diabetes and the complications of pregnancy. Better dental care can mean healthier
employees.
Early dental care may help lower risk for certain illnesses Visit the Dentist Regularly
Recent medical studies suggest a connection between
periodontal disease and complications of cardiovascular disease.
Also, periodontal disease may increase the likelihood for
expectant mothers to deliver their babies early. And it may even
make it more difficult for diabetics to control their blood sugar
levels. But that’s not all: Periodontal disease has been linked to
respiratory infections in people with lung problems.
Regular checkups, cleanings, and maintenance are
important, certainly. But a study from Aetna and
Columbia University College of Dental Medicine
indicates that proactive periodontal care appears to
have a positive effect on the cost of medical care, with
earlier treatment resulting in lower medical expenses
for members with diabetes, coronary
artery disease and stroke.
Page 10 6/5/2019
Effective Date: October 1, 2019
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Participating dentists will not balance bill members.
Offered on an active or passive basis with varying coinsurance, deductible and maximum levels.
Members generally save on dental costs when they see an in network dentist, as coinsurance is applied to a
negotiated rate.
Flexible claims system allows us to accommodate deductibles, coinsurance levels and plan maximums you choose.
Member cost sharing is based on negotiated provider fees.
Freedom-of-Choice:
Packages our DMO® plan with one of our Indemnity or PPO plan options. Members may switch between the
plans as often as monthly. Employers pay one blended rate.
Dental PPO
Allows members to choose the dentist they want and pay deductibles and coinsurance up to an annual maximum.
Packages our DMO® plan with one of our Indemnity or PPO plan options. Members choose between the plans
at annual enrollment.
Dual Choice Packages:
Our DMO® plan with another company's dental plan. Members choose between the plans at annual enrollment.
Are offered as either a coinsurance or fixed dollar co-payment plan. Voluntary (employee-pay-all) plans are
also available.
We’re able to package the DMO® in a variety of ways:
Dual Option:
(co-payments may apply).
Ask members to select a participating primary care dentist. Each family member may choose a different dentist
to provide and coordinate care and to refer members to participating dental specialists, as appropriate, under
the terms of the plan.
DMO®
Our DMO® products meets the needs of our members and their families. Our DMO® plans:
Combine comprehensive benefits coverage and cost control features with a robust provider network.
Offer members a broad range of covered services with no deductibles or required annual maximums
You’ll appreciate our:
Innovative technology resources for customers, members and providers
Excellent customer service through dedicated dental service centers
Professional and focused account managers
with evidence that regular dental care is central to the management of overall health.
We’ll work with you to design plans and provide services that meet your need and your budget. Our broad
product spectrum, flexible plan designs, large provider networks and competitive prices make us the leading
choice for dental benefits. We offer a variety of dental plan designs. These include fixed copayment and coinsurance
plans, which allow various options for a healthier tomorrow as your business needs grow and change.
City of Southlake
General Description
Products
Giving members and their families access to the highest quality care, Aetna offers the best value for dental in the
market. We know that oral health influences overall health. As we gather medical and dental data, we’re able to
evaluate and share disease patterns that may otherwise go unnoticed. We’re transforming the dental experience
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City of Southlake
General Description
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We're also able to integrate medical claims data from external medical carriers for an additional cost.
help them change behaviors and reach their best oral and overall health.
We offer this program at no additional cost to customers who have both Aetna medical and dental plans. We
support members through a combination of proactive identification, member outreach and education and
enhanced benefits . Our DMI program is unique in the marketplace and by having medical and dental, we can
make decisions faster than our competitors.
There are no claims with this program.
Programs
Dental Medical IntegrationSM (DMI)
The link between dental and physical health is very real. Our industry-leading DMI program recognizes this
connection and joins members on their journey with a coordinated care approach. We offer enhanced benefits
for at-risk members, and educational outreach to those who are not currently receiving dental care. These benefits
This program is not an insurance plan. Members simply present their Vital Savings ID card when they visit a
participating dental office.
Members are responsible for 100% of the fee and must pay directly to the dentist at the time of service.
We may balance bill members and require them to file claims.
Aetna Vital Savings
Offers access to discounts for dental services from participating dental providers.
Discounts are the same as our PPO discounts (range between 15-50% nationally).
Coverage includes preventive, basic and major services.
Deductibles, coinsurance levels, calendar year maximums and orthodontic maximums typically apply.
Reimbursement based on reasonable and customary determinations and is subject to benefit limitations.
Offered as full-risk or self-funded with the same underwriting guidelines as the PPO plan.
Dental Indemnity
Traditional fee-for-service dental insurance (no network).
Members visit any licensed dentist for covered services.
Benefits for both in- and out-of-network care are based on the PPO-negotiated fee in the member's area.
In-network dentists accept the negotiated fee in full, but out-of-network dentists may balance bill members
up to the dentist's standard fee.
Offered as a standalone or an alternate plan to the DMO Freedom-of-Choice or Dual Option packages.
PPO Max
Includes a large network of dentists and significantly lower premiums.
Allows members to go to dentists in or out-of-network. Encourages the use of in-network services because of
the way we reimburse non-participating providers.
traditional dental PPO network.
Rental providers located throughout the country offer discounts that are typically less than the discounts for
PPO providers.
Increased access can lead to greater member satisfaction and less disruption.
Dental PPO II
This vendor-based network offers even greater access than our dental PPO plan by supplementing our
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City of Southlake
General Description
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Policies and claim settlement practices
This quotation assumes our standard policy provisions and claim settlement practices will apply. This includes
our standard limitations and exclusions, including missing tooth and late entrant provisions for employees who
on the number of members requiring accumulator updates.
If requested, we will accept deductible credits via prior carrier EOB copies from members at no additional cost,
either at the time a claim is submitted or when you request a recalculation of a claim. Cost for getting claim
history from the prior carrier is excluded from the proposed pricing.
Obtaining and uploading prior carrier history
There is no cost for receiving claim history files electronically from the prior carrier if it can be loaded into our
claim system using a standard transfer program. Charges related to non-standard transfers will be assessed
separately based on complexity and format requirements. If the data cannot be transferred electronically, there
will be an additional charge, as accumulators need to be updated manually for all members. Cost will be based
Eligibility transmission
Our proposal assumes we will receive eligibility information monthly or more frequently. Submission of
eligibility information by more than one location or via multiple methods may result in additional charges.
Costs for any custom programming needed to accept eligibility information are excluded. During installation,
we can review all available methods of submitting eligibility information and identify the best approach for you.
fee but can be supplied and bulk-shipped to a single location for an additional $0.13 per employee, per month.
Digital PPO ID cards are available on our secure website and included in our quoted rates.
DMO directories and ID cards
Our rates include the cost for DMO provider directories and digital ID cards.
The majority of members using enhanced benefits visit their dentist for scaling and root planing and
periodontal maintenance, which is the most common treatment to help control gum disease.
Services
Dental PPO directories and ID cards
Get personalized provider information online at www.aetna.com or by calling the toll-free member service
number listed on the back of the member ID card. A full supply of paper directories are not included in the
One extra visit for a routine cleaning
A dental debridement to remove any thick or hard deposits on teeth
Periodontal scaling and root planing
Periodontal maintenance
two outreach phone calls during normal regular business hours. If we can’t reach the member, we send a follow-up
postcard.
Enhanced benefits
Our DMI program offers enhanced benefits to encourage these at-risk members to get the care they need. We
cover specific services at 100 percent, with no deductible, including:
in the past 12 months. With access to both medical and dental claims information, this process is seamless and
allows us to reach members who need the most support. There’s no extra cost or paperwork.
Member education and outreach
Once identified, we send an educational postcard or email to the member. If the member doesn’t see the dentist
within four months after this initial outreach, a dental care coordinator follows up with a phone call. We make
Member identification
We automatically enroll our at-risk members in this program. Our database identifies those who can benefit
from DMI most, like employees with heart disease, diabetes or expectant moms who haven’t been to the dentist
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City of Southlake
General Description
Billing and payment of ASC service fees (ASC)
We prepare a monthly Administrative Services Contract fee statement based on the number of employees
covered that month. You will update the number of lives (if applicable) and forward the appropriate payment.
Late wire transfer charges (ASC)
Our proposal assumes that wire requests will be responded to on a same-day basis. We will assess a late wire
transfer charge if we do not receive the requests on the day we requested them. This charge is equal to the time
weighted amounts of the delayed transfers multiplied by an annualized retention charge factor of 12.0%.
right to apply a run-off processing fee upon cancellation.
Banking (ASC)
You provide funds via wire transfer for drafts issued under the Administrative Services Contract arrangement
assumed in this proposal. We have assumed that you will use no more than one primary banking line.
Additional wire lines and customized banking arrangements will result in an adjustment to proposed pricing.
processing of run-off claims for 12 months following cancellation, subject to the conditions of our financial
guarantee.
Run-off claim processing (ASC immature fees)
Our fees reflect an immature claim base and do not take into account expenses associated with the processing
of run-off claims following cancellation, subject to the conditions of our financial guarantee. We reserve the
Run-in claim processing
Expenses associated with run-in claims from the prior plan (claims incurred prior to the effective date of the
plan) are excluded from proposed pricing scenarios.
Run-off claim processing (ASC mature fees or full-risk)
Our rates reflect an incurred (mature) claim base and take into account the expenses associated with the
enroll other than within 31 days after first becoming eligible for coverage or during an approved "open" annual
enrollment period.
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Effective Date: 10-01-2019
Plan 135(a) External Plan ID 1006803168
Line Value 923
12 12 24
Exam with Dilation as Necessary Aetna Vision Network
Routine/Comprehensive Eye Exam $10 Copay $30 Reimbursement
Standard Contact Lens Fit/Follow-Up Member pays discounted fee of $40 Not Covered
Premium Contact Lens Fit/Follow-Up Member pays 90% of retail Not Covered
Standard Plastic Single Vision Lenses $25 Copay $25 Reimbursement
Standard Plastic Bifocal Vision Lenses $25 Copay $40 Reimbursement
Standard Plastic Trifocal Vision Lenses $25 Copay $55 Reimbursement
Standard Plastic Lenticular Vision Lenses $25 Copay $55 Reimbursement
Standard Progressive Vision Lenses $90 Copay $40 Reimbursement
Premium Progressive Vision Lenses¹
UV Treatment Member pays discounted fee of $15 Not Covered
Tint (Solid And Gradient)Member pays discounted fee of $15 Not Covered
Standard Plastic Scratch Coating $0 Copay $15 Reimbursement
Standard Polycarbonate Lenses - Adult Member pays discounted fee of $40 Not Covered
Standard Polycarbonate Lenses - Children To Age 19 $0 Copay $35 Reimbursement
Standard Anti-Reflective Coating Member pays discounted fee of $45 Not Covered
Polarized And Other Lens Add Ons Member pays 80% of retail Not Covered
Conventional Contact Lenses $110 Allowance **
Additional 15% off balance over allowance $88 Reimbursement
Disposable Contact Lenses $110 Allowance $88 Reimbursement
Medically Necessary Contact Lenses $0 Copay $200 Reimbursement
Any Frame available, including frames for prescription
sunglasses
$130 Allowance **
Additional 20% off balance over allowance $65 Reimbursement
Employee Only $5.91
Employee + Spouse $11.24
Employee + Child(ren)$11.82
Employee + Family $17.38
In Network Discounts
Additional pairs of eyeglasses or prescription
sunglasses2
Non-covered items3
Lasik Laser vision correction or PRK from U.S. Laser
Network4 only. Call 1-800-422-6600
Retinal Imaging5
Up to a 40% Discount
20% Discount
15% discount off retail or 5% discount off the promotional price
Member pays a discounted fee up to $39
Use your Lens coverage once every rolling 12 months to purchase either 1 pair of eyeglass lenses OR 1 order of contact lenses
Frames
Use your frame coverage once every rolling 24 months
Rates - See detailed rate information on page 2
Eyeglass Lenses / Lens options
Use your Lens coverage once every rolling 12 months to purchase either 1 pair of eyeglass lenses OR 1 order of contact lenses
20% discount off retail minus $120 plan allowance plus $90 copay =
member out of pocket $40 Reimbursement
Contact Lenses
Aetna VisionSM Preferred
www.aetnavision.com
Summary of Benefits for City of SouthLake
In Network Out of Network*
Use your Exam coverage once every rolling 12 months
Date Printed: 05-07-2019version 05-19
#Proprietary
Vision insurance plans are underwritten by Aetna Life Insurance Company (Aetna). Certain claims administration services are provided by First American Administrators, Inc. and certain
network administration services are provided through EyeMed Vision Care (“EyeMed”), LLC.
Providers participating in the Aetna Vision network are contracted through EyeMed Vision Care, LLC. EyeMed and Aetna are independent contractors and not employees or agents of each
other. Participating vision providers are credentialed by and subject to the credentialing requirements of EyeMed. Aetna does not provide medical/vision care or treatment and is not
responsible for outcomes. Aetna does not guarantee access to vision care services or access to specific vision care providers and provider network composition is subject to change without
notice.
This quote is based on a contract situs of Texas. Extraterritorial state requirements may apply to members residing in specific States. If your plan covers members in other states, impacts to
your plan of benefits and rates adjustments (if any) will be evaluated and communicated to you at the point of sale.
Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability. Aetna
provides free aids/services to people with disabilities and to people who need language assistance. If you need a qualified interpreter, written information in other formats, translation or other
services, call 877-973-3238. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with Civil
Rights Coordinator by contacting: Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512. 1-800-648-7817, TTY: 711, Fax: 859-425-3379, CRCoordinator@aetna.com.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at
1-800-368-1019, 800-537-7697 (TDD). Help for those who speak another language and for the hearing impaired
For language assistance in your language call 877-973-3238. Para obtener asistencia lingüística en español, llame sin cargo al número que figura en su tarjeta de identificación.
Customer Signature: Date:
**Allowances are one-time use benefits. No remaining balances may be used. The plan does not provide a declining balance benefit.
1Premium progressives and premium anti-reflective Brand designations are subject to annual review and change based on market conditions. Ask your eye care provider for more
information.
2Additional pair discount applies to purchases made after the plan allowances have been exhausted.
3Non covered discounts may not be available in all states.
4Lasik or PRK from the US Laser Network, owned and operated by LCA Vision.
5Retinal Imaging available at participating locations. Contact your eyecare provider to verify if available.
Rate Information
We have made every effort to respond to your request in a manner that reflects existing and expected business practices for the effective date that you have chosen.
Pricing and Underwriting Assumption Our proposal assumes that coverage will be extended to all eligible employees. This quotation is on a pretax basis and will be void for post-tax offerings.
Policies and Claim Settlement Practices Our proposal assumes that our standard contract provisions and claim settlement practices will apply. If a material change is initiated by you due to
legislative or regulatory action in the claim payment requirements or procedures, account structure, or any changes materially affecting the manner or cost of paying benefits, we reserve the
right to adjust our proposal accordingly.
Participation requirements A minimum participation level of 10 enrolled subscribers is required.
Plan Offering We have assumed that Aetna will be the sole Vision vendor offered.
Rate Guarantee Our quoted rates are guaranteed for the first 4 years of the policy period and are valid as of the plan effective date. The quoted rates apply only to the benefit levels and
conditions specified and any variations in benefit level or assumed conditions may require a rate change. We reserve the right to review and modify or terminate the guarantee arrangement if
any of the following occur during the guarantee period:
• Failure to make required premium payments in accordance with policy provisions.
• A material change in the plan of benefits offered that is initiated by you or required because of legislative or regulatory action.
Affordable Care Act – Fees and Assessments The Patient Protection and Affordable Care Act imposes a Health Insurer Fee ( the “Fee”). The Fee became effective on January 1, 2014. The
Fee will be suspended for 2019, but reinstated starting in 2020. This rate quote includes, where permitted, the estimated proportionate allocation of the Fee for the years where the Fee is
applicable.
Plan Eligibility Our quoted rates assume that permanent full-time employees work a minimum of 25 hours per week on a regularly scheduled basis and that eligible dependents include an
employee’s spouse and unmarried children up to age 26.
Run-Off Claim Processing Our quoted rates reflect an incurred (mature) claim base and take into account the expenses associated with the processing of run-off claims following cancellation,
subject to the conditions of our financial guarantee.
Fiduciary Aetna is claim fiduciary
ID Cards Our quoted rates include the cost for standard ID cards. Each vision subscriber will receive two ID cards. The ID card includes a toll-free number for accessing member services.
Commissions - 10% commissions have been included in our rates.
Compensation to Producers (Brokers, Agents and Consultants):
Licensed and appointed producers may earn compensation in the form of a commission on the sale of this product. The amount of compensation varies depending on a number of factors,
including customer segment and the product selected. Aetna offers additional bonus programs to its producers, which may also apply. Please consult your broker for additional information
concerning their compensation for this sale, including commissions and any applicable bonus programs. The producer is prohibited by law from altering the amount of compensation received
from Aetna based in whole or in part on the sale.
Compensation to Salaried Aetna Employees:
Salaried employees may earn compensation on the sale of Aetna products. The compensation varied depending on a number of factors, including customer segment and product selected.
Combining all factors, compensation for each product quoted averages less than 8% of the total first year annual premium. Aetna offers additional bonus programs, which may also apply.
Neither Aetna nor the employee has material ownership interest in the other. The employee may not alter the amount of compensation received from Aetna. You may obtain additional
information about the compensation expected to be received by eligible employees, based in whole or in part on the sale of an Aetna product, or alternative options presented, by contacting
Aetna at www.aetna.com/about-us/forms/employee-compensation-disclosure.html.
Partial list of Exclusions and Limitations
Exclusions and limitations for vision include: any charges in excess of the benefits, dollar or supply limits listed above; special vision procedures, such as orthoptics, vision therapy or vision
training; vision services or supplies that do not meet professionally accepted standards; plano (non-prescription) lenses; non-prescription sunglasses; two pair of glasses in lieu of bifocals;
medical and/or surgical treatment of the eyes; cosmetic services; lost or broken lenses, frames, glasses or contact lenses. Other exclusions and limitations may also apply.
*You can choose to receive care outside the network. Simply pay for the services up front and then submit a claim form to receive an amount up to the out of network reimbursement amounts
listed above. Reimbursement will not exceed the providers actual charge. Claim forms can be found at www.aetnavision.com or by calling customer service Mon-Sun @ 877-9-SEE-AETNA.
Submit completed claim form with receipts to Aetna, PO Box 8504 Mason, OH 45040-7111.
Enrolled members can access our secure member website once their plan becomes effective. Enrolled subscribers will receive a welcome packet with ID card mailed to their home within 15
business days after enrollment is processed.
Date Printed: 05-07-2019version 05-19
#Proprietary