october 1, 2012 – december 31, 2013 cape coral professional firefighters health insurance trust

October 1, 2012 – December 31, 2013

Cape Coral Professional FirefightersHealth Insurance Trust

Benefit and Eligibility Information 1

Medical Plans 2

Side-by-side Comparisons 3-4

Aetna Value Adds 5

Benefit Resource Center 6

Newborns’ and Mothers’ Health Protection Act

Women’s Health And Cancer Rights Act 7

Medicare Part D 8

HIPAA Privacy 9

Important Contact Information 10

Table Of Contents

This illustration is intended to give a brief overview of benefits offered. Refer to the contract/proposal/plan document for a detailed, accurate description of benefits. This is an illustration based on estimated enrollment numbers. Final rates will be based on actual enrollment, plan design chosen and plan effective date. Every attempt has been made to accurately reflect the details of the plan, should there be any errors, the terms and conditions of the summary plan description/contract prevail.

Benefit Information

Your Benefits Plan

Cape Coral Professional Firefighters Health Insurance Trust

offers three medical benefit options for you to choose from.

The following pages will provide a basic summary of each plan

offered.

Eligibility

You are eligible to join the Trust Benefit Plan on your date of

hire.

You may also enroll your dependents in the Trust Benefit Plan

when you enroll. Eligible dependents include:

Your spouse, unless you are legally separated or

divorced;

A dependent who is 26 years of age or younger

Under the plan children include your natural children, step-

children living with you, legally adopted children and any other

children for whom you have legal guardianship.

1

When Can You Enroll?You can sign up for benefits at any of the following times:

When hired as a firefighter by the City of Cape Coral Fire Department for continuous, full-time employment;

During the annual open enrollment period; Within 30 days of a qualified family-status change.

If you do not enroll at the above times, you must wait for the next annual open enrollment period.

Extended Dependent CoverageFor medical coverage only, extended coverage may be offered for dependent children up to the end of the calendar year in which your dependent reaches age 30, if they meet the following requirements:

- Unmarried and do not have dependents of their own

- Are a resident of Florida or a student, AND

- Do not have coverage as a named subscriber, enrollee, or covered person under any other group insurance policy or individual health plan or entitled to Medicare benefits.

Medical plans

About Your Medical Options

For most people, medical insurance is no longer a “want” – it’s

a need. We’ve all seen the cost of medical care skyrocket

over the years, so we need insurance to help protect not only

our physical fitness – but our financial fitness, as well.

Cape Coral Firefighters Health Insurance Trust offers you

three medical plans to choose from - all through Aetna.

Benefits will vary depending on the plan you and your family

choose.

Under the Health Network Only Plan ( HMO), members are

allowed to utilize doctors and facilities only in the Aetna Health

Network Only network. The Health Network Option Plan

(POS), provides members with the flexibility of utilizing doctors

and facilities in or out of the Aetna Network. If a member

utilizes care out-of-network, then their out-of-pocket costs will

be higher than with a participating Aetna provider. Members

are not required to choose or utilize a PCP (Primary Care

Physician), but it is recommended that you do. The third plan

is the Health Network Option (HDHP), a high deductible plan,

which also gives members the flexibility of utilizing providers

in or out of the Aetna Network.

On the following page you can compare the above mentioned

plans side-by-side. There’s sure to be a medical option that

will help you and your eligible dependents stay physically and

financially fit.

Key Benefit Terms

COBRA – A Federal law that allows workers and dependents

who lose their medical coverage to continue any of these

coverages for a specified length of time by electing and paying

for continuation benefits.

Coinsurance – The percentage of the medical charge that you

pay after the deductible has been met.

Copayment – A flat fee that you pay for medical services,

regardless of the actual amount charged by your doctor or

another provider. This generally applies to physician office

visits and prescription drugs.

Deductible – The amount you pay toward medical expenses

each calendar year before the plan begins paying benefits.

Maximum out of Pocket – The maximum amount (includes

coinsurance and deductible) that an insured will have to pay

for covered expenses under a plan. Once the out-of-pocket

maximum is reached, the plan will cover eligible expenses at

100%.

2

Aetna Network

Open Access HMOHealth Network Only

Open Access POSHealth Network

Options

Open Access HDHPHealth Network

Options

In-Network Benefits

Calendar Year Deductible (Individual/Family) None/None $500/$1,000 $1,500/$3,000

Out-of-Pocket Maximum (Individual/Family) (Includes Deductible and Coinsurance )

$3,000/$6,000 (co-pays accumulate towards out-of-

pocket maximum)

$3,500 /$7,000(coinsurance and deductible

accumulate towards out-of-pocket maximum)

$5,000 /$10,000coinsurance and deductible

accumulate towards out-of-pocket maximum)

Coinsurance (Based on Contracted Rate) 100% 80% 80%

Annual Maximum Unlimited Unlimited Unlimited

Physician Services

Preventive CareRoutine Adult Physical Exam and Immunizations

Well Woman Exam

Mammograms

Colonoscopy (Routine for age 50+, then frequency schedule applies)

Well Child Care

100%, deductible does not apply



Office Services

Office Visits-PCP

Office Visits-Specialist Allergy Injections

$15 copay

$25 copay


$15 copay

$30 copay

$20 copay

$20 copay

Inpatient & Outpatient Services

Urgent Care Centers

Emergency Room Facility Services

Provider Services at ER and Hospital

Provider Services Radiology and Anesthesiology at an Ambulatory Surgical Facility

$50 copay

$150 copay



$40 copay

$125 copay

80% after deductible


$50 copay

$100 copay



Outpatient Diagnostic Services

Independent Clinical Lab

Independent Diagnostic Testing Facility

Outpatient Hospital Facility Services

Independent Advanced Imaging Facility (MRI, CAT, PET Scans)








$125 copay





3

As you can see, the plan is designed to combine in-depth coverage with cost-effective prices. This summary contains highlights only and is subject to change. The

specific terms of coverage, exclusions and limitations including legislated benefits are contained in the Summary Plan Description or Insurance Certificates. This plan is

insured and / or administered by Aetna. PLEASE NOTE THAT OUT-OF-NETWORK SERVICES ARE SUBJECT TO BALANCE BILLING.

4

Aetna Network

Open Access HMOHealth Network Only

Open Access POSHealth Network

Options

Open Access HDHPHealth Network

Options

In-Network Benefits – Continued

Hospital / Surgical

Inpatient Hospital Facility

Physician, specialists and surgeon services; anesthesia, oxygen, drugs and medication

Outpatient Hospital Facility Services

Outpatient Surgical Center

$500 copay




$600 copay



$200 co-pay





Other Services

Mental Health / Substance Abuse

Inpatient Hospital

Provider Services/Office Visits$500 copay

$15 copay per visit

$600 per admission deductible waived

$15 copay per visit


$20 copay per visit

Out-of-Network Benefits

Deductible

Coinsurance

Out-of-Pocket Maximum

Not Available

$2,000 /$4,000

60%

$5,000 /$10,000

$3,000 /$4,000

60%

$9,000 /$18,000

Prescription Drugs

Annual Prescription Deductible

Individual / Family None / None None / None None / None

Tier 1 (Deductible waived) $10 copay $10 copay $10 copay

Tier 2 $30 copay $30 copay $30 copay

Tier 3 $50 copay $50 copay $50 copay

Mail Order 2.5 x retail copay 2.5 x retail copay 2.5 x retail copay

Bi-Monthly Employee Costs

Employee

Employee + Spouse

Employee + Child(ren)

Family

$0.00

$151.13

$83.70

$235.18

$0.00

$191.35

$106.72

$291.08

$0.00

$124.59

$68.91

$193.98

Prescription Drug Benefits at a Reduced Cost – Did you know you can obtain prescription drugs at local retailers at a reduced cost and sometimes even free? Publix offers a variety of generic Oral Antibiotic medications to you absolutely free. Bring in your prescription for an approved medication and receive it FREE, up to a 14-day supply. Publix recently approved a medication for diabetes. CVS, Target, Walgreens & WalMart also offer over 400 generic prescriptions for $4 and a 90 day supply for approx. $10 . Remember DO NOT show your Aetna ID card to receive these benefits, or you will be charged your Aetna drug rate.

Member Resources

Aetna Navigator ® Secure Member Website – Aetna Navigator is your secure member website. It’s where you go to:

Find doctors, dentists, pharmacies & hospitalsGet an ID card Look up a claimYou’re mobile. So are we.Check your coverageKeep track of health care costsIt’s personalized for you and your familyIt’s easy to get started – www.aetnanavigator.comYou can also get a summary of your doctor visits, medical tests, prescriptions and other health activities. Look up health topics. Complete a Health Assessment.

Beginning Right® Maternity Program

Helping you and your baby grow healthy – togetherYou get the Beginning Right Maternity management program with your Aetna plan.Information for a healthier pregnancy – You will get materials on – Prenatal care – Preterm labor symptoms – What to expect before/after delivery – Newborn care and moreSpecial attention for Pregnancy risksSolid support to quit smoking

Aetna Discount Programs

Gym MembershipsEyeglasses and contactsWeight-loss programs ( Jenny Craig® - Nutrisystem® - eDiets® )Chiropractic visitsMassage therapyAcupunctureHearing aids and more

Personal Health Record

Access family history detailsReview your office visits, prescriptions, conditions & treatmentsGet a health summaryDownload & share your information easily with health care providersReceive important medical alertshttp://healthyis.aetna.com/personalhealth

24-hour Nurse Line for Health Questions

1. Call a registered nurse toll-free2. Visit member site www.aetna.com3. Listen to Audio Health Library

In addition to the network of physicians, hospitals, emergency rooms, and urgent care clinics, you also have the option of going to the convenient care clinics located within some grocery and drug stores, for minor illness such as ear aches, colds, flu and so on. By selecting one of these providers, you pay only the regular office visit copay; a significant savings over the emergency room and urgent care copayments.

Please visit the various websites for locations, hours of operations and scope of services.

CVS Minute Clinic: www.cvs.com

Publix Little Clinic: www.Publix.com

Walgreen’s Take Care Clinic: www.walgreens.com

Aetna Value Adds

Frequently Asked Questions About Your Medical Plan

Q. What should I do if I have a problem getting a claim paid?

A. Start by contacting the carrier’s member services number to determine

the nature of the problem. If the issue is the way the doctor or other service

provider has billed the claim, then contact your doctor or Claims Advocate at

USI. If the insurance company has an eligibility issue, contact Human

Resources for assistance.

Q. What is the difference between brand formulary, brand non-

formulary, and generic drugs?

A. Brand formulary is a prescription drug that is listed on the formulary (i.e.,

a list of prescription drugs covered by the plan). These drugs are protected by

a patent issued to the original innovator or marketer. Brand non-formulary

drugs are patent protected but are not listed. A generic equivalent drug can

become available when the patent protection runs out, and is deemed equal in

therapeutic power to the brand name originals.

Q. When should I go the Urgent Care vs. Emergency Room?

A. For non-life threatening injury/illness after normal doctor’s office hours.

5

http://www.aetnanavigator.com/

http://healthyis.aetna.com/personalhealth

http://www.aetna.com/

http://www.cvs.com/

http://www.publix.com/

http://www.walgreens.com/

Toll-free benefit call center available to:

• Answer questions regarding your health and other benefit plans

• Network: Is my doctor on the plan?• Plan Coverage: Does my plan cover this?• Billing: I received a bill from my provider, do I need to

pay?• Once you’ve tried, but need help understanding how a carrier

paid your claim • Specialist support to help you with complex claims issues• Medical appeals information and support• Life event (family status) rules – what changes can I make?• Life Insurance Beneficiary form requirements• How do I complete an Evidence of Insurability form and

where do I send it?• What happens if I have coverage under two different medical

plans?

Benefit Resource Center Services

6

Required Annual Employee Disclosure Notices

The Newborns’ and Mothers’ Health Protection Act

of 1996

The Newborns’ and Mothers’ Health Protection Act of 1996 prohibits

group and individual health insurance policies from restricting benefits

for any hospital length of stay for the mother or newborn child in

connection with childbirth; (1) following a normal vaginal delivery, to

less than 48 hours, and (2) following a cesarean section, to less then

96 hours. Health insurance policies may not require that a provider

obtain authorization from the health insurance plan or the issuer for

prescribing any such length of stay. Regardless of these standards an

attending health care provider may, in consultation with the mother,

discharge the mother or newborn child prior to the expiration of such

minimum length of stay.

Further, a health insurer or health maintenance organization may not:

1. Deny to the mother or newborn child eligibility, or continued

eligibility, to enroll or to renew coverage under the terms of the

plan, solely to avoid providing such length of stay coverage;

2. Provide monetary payments or rebates to mothers to encourage

such mothers to accept less than the minimum coverage;

3. Provide monetary incentives to an attending medical provider to

induce such provider to provide care inconsistent with such

length of stay coverage;

4. Require a mother to give birth in a hospital; or

5. Restrict benefits for any portion of a period within a hospital

length of stay described in this notice.

These benefits are subject to the plan’s regular deductible and co-pay.

For further details, refer to your SPD. Keep this notice for your

records and call your Trust for more information.

Women’s Health and Cancer Rights

Act of 1998

The Women’s Health and Cancer Rights Act of 1998 requires Cape

Coral Professional Firefighters to notify you, as a participant or

beneficiary of the Cape Coral Professional Firefighters, Local 2424

Health and Welfare Plan, of your rights related to benefits provided

through the plan in connection with a mastectomy. You, as a

participant or beneficiary, have rights to coverage to be provided in a

manner determined in consultation with your attending physician for:

1. All stages of reconstruction of the breast on which the

mastectomy was performed;

2. Surgery and reconstruction of the other breast to produce a

symmetrical appearance; and

3. Prostheses and treatment of physical compilations of the

mastectomy, including lymphedema.

These benefits are subject to the plan’s regular deductible and co-pay.

For further details, refer to your SPD. Keep this notice for your

records and call Human Resources for more information.

7

Children’s Health Insurance Program

Reauthorization Act (CHIPRA) of 2009

Effective April 1, 2009, a special enrollment period provision is added

to comply with the requirements of the Children’s Health Insurance

Program Reauthorization Act (CHIPRA) of 2009. If you or a

dependent is covered under a Medicaid or CHIP plan and coverage is

terminated as a result of the loss of eligibility for Medicaid or CHIP

coverage, you may be able to enroll yourself and/or your

dependent(s). However, you must enroll within 60 days after the date

eligibility is lost. If you or a dependent becomes eligible for premium

assistance under an applicable State Medicaid or CHIP plan to

purchase coverage under the group health plan, you may be able to

enroll yourself and/or your dependent(s). However, you must enroll

within 60 days after you or your dependent is determined to be eligible

for State premium assistance. Please note that premium assistance is

not available in all states.

Section 111

Effective January 1, 2009 group health plans are required by Federal

government to comply with Section 111 of the Medicare, Medicaid, and

SCHIPExtensions of 2007’s new Medicare Secondary Payer

regulations. The mandate is designed to assist in establishing

financial liability of claims assignments. In other words, it will help

establish who pays first. The mandate requires group health plans to

collect additional information, more specifically Social Security

numbers for all enrollees, including dependents 6 months of age or

older. Please be prepared to provide this information on your benefits

enrollment form when enrolling into benefits.

Required Annual Employee Disclosure Notices

Medicare Part DThis notice applies to employees and covered dependents who are

eligible for Medicare Part D.

Please read this notice carefully and keep it where you can find it.

This notice has information about your current prescription drug

coverage with Cape Coral Firefighters Local 2424, and prescription

drug coverage available for people with Medicare. It also explains the

options you have under Medicare prescription drug coverage and can

help you decide whether or not you want to enroll. At the end of this

notice is information about where you can get help to make decisions

about your prescription drug coverage.

Medicare prescription drug coverage became available in 2006

to everyone with Medicare through Medicare prescription drug

plans and Medicare Advantage Plans that offer prescription drug

coverage. All Medicare prescription drug plans provide at least a

standard level of coverage set by Medicare. Some plans may

also offer more coverage for a higher monthly premium.

Because your existing coverage is on average at least as good as

standard Medicare prescription drug coverage, you can keep this

coverage and not pay extra if you later decide to enroll in

Medicare prescription drug coverage.

Individuals can enroll in a Medicare prescription drug plan when they

first become eligible for Medicare and each year from October 15th

through December 7th. Beneficiaries leaving employer/union

coverage may be eligible for a Special Enrollment Period to sign up for

a Medicare prescription drug plan.

You should compare your current coverage, including which drugs are

covered, with the coverage and cost of the plans offering Medicare

prescription drug coverage in your area.

If you do decide to enroll in a Medicare prescription drug plan

and drop your Cape Coral Professional Firefighters, Local 2424

prescription drug coverage, be aware that you and your

dependents may be able to get this coverage back. Please

contact us for more information about what happens to your

coverage if you enroll in a Medicare prescription drug plan.

You should also know that if you drop or lose your coverage with Cape

Coral Firefighters, Local 2424 and don’t enroll in Medicare prescription

drug coverage after your current coverage ends, you may pay more

(a penalty) to enroll in Medicare prescription drug coverage later.

If you go 63 days or longer without prescription drug coverage that’s at

least as good as Medicare’s prescription drug coverage, your monthly

premium will go up at least 1% per month for every month that you did

not have that coverage. For example, if you go nineteen months

without coverage, your premium will always be at least 19% higher

than what many other people pay. You’ll have to pay this higher

premium as long as you have Medicare prescription drug coverage. In

addition, you may have to wait until the following November to enroll.

For more information about this notice or your current

prescription drug coverage…

Contact our office for further information (see contact information

below). NOTE: You will receive this notice annually and at other times

in the future such as before the next period you can enroll in Medicare

prescription drug coverage, and if this coverage through Cape Coral

Professional Firefighters, Local 2424 changes. You also may request

a copy.

For more information about your options under Medicare

prescription drug coverage…

More detailed information about Medicare plans that offer prescription

drug coverage is in the “Medicare & You” handbook. You’ll get a copy

of the handbook in the mail every year from Medicare. You may also

be contacted directly by Medicare prescription drug plans. For more

information about Medicare prescription drug plans:

Visit www.medicare.gov

Call your State Health Insurance Assistance Program (see your

copy of the Medicare & You handbook for their telephone

number) for personalized help,

Call 1-800-MEDICARE (1-800-633-4227). TTY users should call

1-877-486-2048.

For people with limited income and resources, extra help paying for

Medicare prescription drug coverage is available. Information about

this extra help is available from the Social Security Administration

(SSA) online at www.socialsecurity.gov, or you call them at 1-800-

772-1213 (TTY 1-800-325-0778).

Remember: Keep this notice. If you enroll in one of the new

plans approved by Medicare which offer prescription drug

coverage, you may be required to provide a copy of this notice

when you join to show that you are not required to pay a higher

premium amount.

Name of Entity/Sender: Cape Coral Professional Firefighters,

Local 2424

Contact--Position/Office: Sharon Thompson (239) 458-2424

8

Required Annual Employee Disclosure Notices continued

I. No access to protected health information (PHI)

except for summary health information for limited

purpose and enrollment / dis-enrollment information.

Neither the group health plan nor the plan sponsor (or any

member of the plan sponsor’s workforce) shall create or

receive protected health information (PHI) as defined in

45 C.F.R. §160.103 except for (1) summary health

information for purpose of (a) obtaining premium bids or

(b) modifying, amending, or terminating the group health

plan, and (2) enrollment and dis-enrollment information.

II. Insurer for group health plan will provide privacy

notice

The insurer for the group health plan will provide the

group health plan’s notice of privacy practices and will

satisfy the other requirements under HIPAA related to the

group health plan’s PHI. The notice of privacy practices

will notify participants of the potential disclosure of

summary health information and enrollment / dis-

enrollment information to the group health plan and the

plan sponsor.

III. No intimidating or retaliatory acts

The group health plan shall not intimidate, threaten,

coerce, discriminate against, or take other retaliatory

action against individuals for exercising their rights , filing

a complaint, participating in an investigation, or opposing

any improper practice under HIPAAA.

IV. No Waiver

The group health plan shall not require an individual to

waive his or her privacy rights under HIPAA as a

condition of treatment, payment, enrollment or eligibility.

If such an action should occur by one of the plan

sponsor’s employees, the action shall not be attributed

to the group health plan.

9

HIPAA Privacy Policy for Fully Insured Plans with no Access to PHI

The group health plan is a fully insured group health plan sponsored by the “Plan Sponsor”. The group health plan and the plan sponsor intend to comply with the requirements of 45 C.F.R. §164.530 (k) so that the group health plan is not subject to most

of HIPAA’s privacy requirements.

Michelle’s Law

The law allows for continued coverage for dependent children who are

covered under your group health plan as a student if they lose their

student status because of a medically necessary leave of absence

from school. This law applies to medically necessary leaves of

absence that begin on or after January 1, 2010.

If your child is no longer a student, as defined in your Certificate of

Coverage, because he or she is on a medically necessary leave of

absence, your child may continue to be covered under the plan for up to

one year from the beginning of the leave of absence. This continued

coverage applies if your child was (1) covered under the plan and (2)

enrolled as at student at a post-secondary educational institution

(includes colleges, universities, some trade schools and certain other

post-secondary institutions).

Your employer will require a written certification from the child’s

physician that states that the child is suffering from a serious illness or

injury and that the leave of absence is medically necessary.

Patient Protection:

If the Group Health Plan generally requires the designation of a primary

care provider who participates in the network and who is available to

accept you or your family members. For children, your may designate a

pediatrician as the primary care provider.

You do not need prior authorization from the carrier or from any other

person (including a primary care provider) in order to obtain access to

obstetrical or gynecological care from a health care professional in the

network who specializes in obstetrics or gynecology. The health care

professionals, however, may be required to comply with certain

procedures, including obtaining prior authorization for certain services,

following a pre-approved treatment plan or procedures for making

referrals.

For a list of participating health care professionals who specialize in

obstetrics or gynecology, or for information on how to select a primary

care provider, and for a list of the participating primary care providers,

contact the Plan Administrator or refer to the carrier website.

It is your responsibility to ensure that the information provided on your

application is accurate and complete. Any omissions or incorrect

statements made by you on your application may invalidate your

coverage. The carrier has the right to rescind coverage on the basis of

fraud or misrepresentation.

Important Contact Information

Carrier/Vendor Plan Phone Number Website

Aetna Medical 800-370-4526 www.aetnacom

Benefit Resource

CenterAdvocacy Assistance 855-674-6699 [email protected]

USI –

Wanda Champagne

Medical, Rx and Health

Advocate954.-607-4127 [email protected]

If you have questions about any of the benefits or services described in this Guide, please contact the

carrier or vendor that handles the plan administration. Toll-free customer service telephone numbers and

websites are listed below for your reference.

10

october 1, 2012 – december 31, 2013 cape coral professional firefighters health insurance trust

Documents

plan children

trust benefit plan

individual health plan

summary plan

medical insurance

plan design

plan hmo

medical coverage