TERMINATION OF COVERAGE 21 1. If more space i s needed to list dependents, please use a separate form and attach it to this application. The plan is insured by Aetna Life Insurance Company (Aetna). Coverage Dates and Rates . Plan Number FOR OFFICE Wakefern Food Corp 725219 USE ONLY 4. 2021 - 2022 Base Plan Students Voluntary Dependent Enrollment Form In order to enroll you must complete steps 1 through 6! Effective 01/01/2021 B. 1. 5 Member cost-sharing waivers for covered in-network telemedicine visits for outpatient behavioral and mental health counseling services for Commercial plans were active until January 31, 2021. . Coverage for dependents eligible under the Plan for the following Coverage Periods. University of Notre Dame 2020-2021 Page 4 . Medical. The Plan offers a choice between two Dental Plan Options: OPTION 1: Dental Maintenance Organization (DMO®) Plan Option Simply select a Primary Care Dentist who participates in the Aetna Dental Aetna Student Health Dental Plan Design and Benefits Summary Preferred Provider Organization (PPO) . The dependent(s) must meet the eligibility requirements, and an Affidavit of Dependent Eligibility (26 -30 years old) must be completed for each dependent in order to continue coverage for that dependent. Fashion Institute of Technology 2020-2021 Page 2 Proprietary . The Plan is available for Saint Martin's University students and their eligible dependents. The exception to this is if you are interested in participating in a Health Care or Dependent Care Flexible Spending Account (FSA). The Dependent rates are published in the 2021-2022 Plan Design and Benefits Summary document which may be viewed at Aetna Student Health's website. dependents terminates in accordance with the Termination Provisions described in the certificate of coverage . Retirement Plan Contribution Limits The 2021 elective deferral limit for 457(b) plans is $19,500. D. ELIGIBLE DEPENDENTS TO BE COVERED / PRIMARY CARE PHYSICIAN SELECTION: *If you choose Aetna HMO coverage, you MUST include an Aetna in-network primary care physician (PCP) for yourself, spouse and all eligible dependents. Ending coverage under the plan doesn't necessarily mean you lose coverage with us. If you participate in the 2020 Health Care Spending Account and/or Dependent Care Spending Account, or Health Savings Account (if applicable), you need to re-enroll for 2021. . 3 2021-2022 EMPLOYEE BENEFITS GUIDE MEDICAL PLANS: AETNA . Contact Aetna Student Health at 877-261-8403 for assistance. Preface . Complete all Student information. The fee for the 2021 - 2022 Student Medical Plan is $1596 per semester. Control No. Your coverage typically ends when you leave your job. Spring 2022 Open Enrollment Deadline is January 26th, 2022. You may choose to pay for your dependents by payroll deduction or direct pay with a credit card Coverage for all insured students will become effective at 12:01 AM on the Coverage Start Date indicated below and will terminate at 11:59 PM on the Coverage End Date indicated. eligible dependents. Contact Aetna Student Health at 877-261-8403 for assistance. In case of any The exact provisions, . Get the best quote and save 30% today! Associates on Service Contract Act (SCA) applicable assignments who qualify (must be classified as non-exempt and work full -time) will be eligible for health insurance coverage starting the first of the month following one full calendar month on assignment. Here's a few things you'll want to know. The annual plan year deductible for dental coverage for the 2021 plan year (January 1, through December. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). You start coverage after you complete the eligibility and enrollment process. $21.50 . Member Plus 1 Dependent. The plan is available for Seattle University students and their eligible dependents. The exact provisions, including Eligibility and Enrollment 4 . Coverage for insured dependents terminates in accordance with the Termination Provisions described in the Master Policy. Critical illness insurance is a policy that provides a lump-sum benefit when you are diagnosed with a covered critical illness like a heart-attack, stroke and other serious conditions - even cancer if it's included in your policy. See all legal notices. Coverage for eligible students will become effective at or after 12:00 a.m. on the coverage dates indicated on the Master Policy, and will terminate at or before 11:59 p.m. on the coverage dates on the Master Policy. Complete all Student information. $19.00 . Aetna Student Health Plan Design and Benefits Summary. Dependent coverage is not an available option. Contact Aetna Student Health at 877-261-8403 for assistance. We're honored to be continuing our journey with the Guam community, delivering health insurance coverage and well-being resources to GovGuam active employees, retirees, survivors and families. Annual 08/01/2021-07/31/2022 Complete all Student information. To learn more see the Who the plan covers section. Coverage for all insured students and eligible dependents will become effective at 12:01 AM on the Coverage Start Date indicated below, and will terminate at 11:59 PM on the Coverage End Date indicated. Aetna Student Health . The cost for the Aetna Dental PPO Insurance Plan is included in the Emory University Student Health Insurance Plan . 1. Coverage for in sured dependents terminates in accordance with the Termination Provisions described in the Certificate of Coverage. . you and your eligible dependents. Eligible Dependents: Coverage will become effective on the same date the insured student's coverage is effective. Aetna to extend dependent coverage up to age 26 Aetna knows many families are worried about their dependents losing medical coverage when they graduate from high school or college or otherwise age out of coverage. If you currently have two IRS . Student Health Insurance Plan Eastern Washington University 2020-2021 Additional Benefits • Access to telemedicine services • Coverage when traveling • Academic Emergency Services AHP (20) AETNA-EWU The insurance carrier for 2020-2021 is Aetna. Incomplete information will delay processing! Depending on the coverage you choose, this insurance will help pay toward or completely cover annual physicals, doctor visits, hospitalization and emergency room visits. Aetna"), provides certain administrative services to the . 2021: Penn Medical Plans and Prescription Drug Coverage Contributions (Hired after 1/1/2006) Medical Non‐Medicare Eligible Aetna Choice POS II Keystone / AmeriHealth HMO PennCare / Personal Choice (PPO) Retiree (Single) $210 $168 $255 Retiree + 1 $664 $636 $712 Retiree + 2 or more $1,117 $1,105 $1,169 Please review the Aetna 2021 Booklet for further details on the Health Plan options. Plan Design and Benefits Summary Fashion Institute of Technology . Covered students may also enroll their lawful spouse, civil union partner, domestic partner (same-sex, opposite sex), and dependent children up to the age of 26. Only non-occupational injuries Dependents Enroll at www.aetnastudenthealth.com Please follow the instructions included to enroll in the Subsidy Eligible Graduate Assistant Insurance program for coverage beginning January 1, 2021 through July 31, 2021. This Aetna Dental® Preferred Provider Organization (PPO) benefits summary is provided by Aetna Life Insurance Company for some of the more frequently performed dental procedures. Effective Date: 01-01-2021 (a) a non-occupational disease; or (b) a non-occupational injury. coverage fee. Dependent Coverage Eligibility . regardless of the health plan selected. Remember: You must add dependents to your NU-SHIP coverage during your appropriate open enrollment period (see above) at the start of each new policy year. 4 of 8 Aetna's liberalized coverage of Commercial telemedicine services, as described in its telemedicine policy, will continue until further notice. Health benefits and health insurance plans contain exclusions and limitations. Hospital Indemnity insurance provides a cash benefit for every day, week or month you are hospitalized. Enrollment To enroll the dependent(s) of a covered student, please complete the Enrollment Form by visiting www.aetnastudenthealth.com Dependents must enroll in same benefit option as the employee. APPLICATIONS WITH MISSING INFORMATION WILL NOT BE PROCESSED. The exact . Your coverage typically ends when you leave your job. Aetna will honor ^Agent of Record _ or ^ roker of Record _ letters when an agent, broker Fall Spring/Summer Coverage Start Date 07/24/2020 . remaining dollars may be used to supplement the cost of the dependent coverage. Member Plus 2 or More Dependents. Saint Martin's University 2021-2022 Page 2 This is a brief description of the Student Health Plan. 2021 - 2022 Medical & 2 Year MBA Students Dependent Enrollment Form - Newborn QLE In order to enroll you must complete steps 1 through 6! Although the national trend in healthcare expenses has been rising between 7% - 8% annually, there will be no increase for dependent coverage for the Premier, Premier Plus and Premier Choice Plans in 2021; however . This benefit may also be available to your spouse . •Detailed plan benefits and coverage can be found on the Aetna Student Health website; . The plan is insured by Aetna Health and Life Insurance Company (Aetna). Hospital Indemnity insurance provides a cash benefit for every day, week or month you are hospitalized. Under the Dental Preferred Provider Organization (PPO) plan, you Domestic partners may be covered as eligible dependents if the . Does aetna insurance cover deviated septum surgery. The 2021 maximum monthly pre-tax contribution limit for mass transit and parking is $270. Incomplete information will delay processing! In case of a discrepancy between the Plan Documents, and this ("Duke") and their eligible dependents. Coverage for all insured students and eligible dependents will become effective at 12:01 AM on the Coverage Start Date indicated below and will terminate at 11:59 PM on the Coverage End Date indicated. A Nationwide Vision Plan, available nationwide and overseas IMPORTANT • Rates: Back Cover • Changes for 2021: Page 4 • Summary of Benefits: Page 22 Enrollment options for this plan: • High Option - Self Only • High Option - Self Plus One • High Option - Self and . Current Anthem Blue Cross Select HMO members will need to switch to another Aetna medical plan. 2021-2022 Student Health Insurance Plan . This SPD may be an electronic version of the SPD on file with Trinity Health and Aetna. 2 . Coverage for insured . . Verifying Coverage . insure their eligible dependents at the same level. Proprietary 795548-911150-529001 1 of 7 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services BAPTIST HEALTH SOUTH FLORIDA, INC.: Aetna Choice® POS II - Pineapple Premier Plan Coverage Period: 01/01/2022-12/31/2022. Golden West College 2021-2022 Page 2 . 3/19/2021 8:06:51 AM . 2021 - 2022 International & PA Allied Health Students and Dependents Continuation Plan Enrollment Form In order to enroll you must complete steps 1 through 6! If more space i s needed to list dependents, please use a separate form and attach it to this application. Coverage for insured dependents terminates in accordance with the Termination Provisions described in the Certificate of Coverage. have been incurred by me or by an individual who is enrolled in the plan who qualifies as my spouse or my dependent under IRS guidelines, and that . $19.00 . Member Plus 2 or More Dependents. Coverage through the Plan is offered to benefits-eligible Colleagues of Trinity Health Corporation ("Trinity Health") and the Trinity Health Ministries and Trinity Health affiliates that have adopted the Plan and their eligible Dependents. Employer Information 1. 2021 . A Nationwide Vision Plan, available nationwide and overseas IMPORTANT • Rates: Back Cover • Changes for 2021: Page 4 • Summary of Benefits: Page 22 Enrollment options for this plan: • High Option - Self Only • High Option - Self Plus One • High Option - Self and . The plan is available for Case Western Reserve University students and their eligible dependents. Aetna VisionSM Preferred www.aetnafeds.com 1-855-347-6899 . In Network vs. Out of Network. Incomplete information will delay processing! Policy Year: 2020 - 2021 Policy Number: 686169 . Administered by Aetna International Effective Date: July 1, 2021 Note: This is not evidence of coverage. Most policies have additional features that help with out of pocket costs related to medical care. Coverage for eligible students will become effective at or after 12:00 a.m. on the coverage dates indicated on the Master Policy, and will terminate at or before 11:59 p.m. on the coverage dates on the Master Policy. 13 Aetna Select EPO 16 HDHP Aetna Choice POS II (PPO) 19 Health Savings Account . It can take several weeks for the card to go out after coverage becomes effective. This money can be used for anything from minimizing out of pocket costs to other expenses . Most policies have additional features that help with out of pocket costs related to medical care. Medical insurance, also known as health insurance, is coverage that helps you pay the high cost of medical and hospital expenses. Coverage through the Plan is offered to benefits-eligible Colleagues of Trinity Health Corporation ("Trinity Health") and the Trinity Health Ministries and Trinity Health affiliates that have adopted the Plan and their eligible Dependents. Learn more on page 34. District of Columbia Public Schools | 2021 Page 10 of 44 41 $) 41 41 AFSCME (10-Month) Health Benefits Plan Premium Rates AETNA HEALTHCARE CONSUMER DRIVEN HEALTH PLAN (CDHP) Aetna CDHP Health Plan Summary TYPE ENROLLMENT CODE 2021 PREMIUM BI-WEEKLY 2021 PREMIUM MONTHLY Self-Only HM1 $ 41.61 $ 91.55 Self + 1 HM2 $ 81.79 $ 179.95 based on the tier you elect for your coverage. While medicare insurance will not cover. To view minor changes for 2021, see the amendment at the end of the "book". Our dental plans stand alone—so you can cover some, all or none of your dependents from your medical plan. th t. he Coverage Administrator before the benefits described in this document will be effective. Eligibility, Enrollment Information, Dates and Deadlines, Prorate for Qualifying . An expense is "incurred" on the day you receive a health care service or supply. It is important to note too, if you do not log on and make changes, your non-HMO coverage will remain the same for the 2021 plan year, and your Dependent Care Spending Account or Health Savings Account will end with the 2020 plan year. Hospital Indemnity Plan. . Aetna.com ©2021 Aetna Inc. STATE-DE-0002.2 (04/21) Table of Contents. The plan is insured by Aetna Life Insurance Company (Aetna). For the plan year 2021, that rate is $1,180.00 per month in addition to any other applicable tier of medical premiums. Incomplete information will delay processing! Aetna is the brand name used for products and services provided by one or more of the Aetna Aetna Choice® POS II Medical Plan Department of Defense Nonappropriated Fund Health Benefits Program Summary of Benefits effective January 1, 2021 Plan Provisions Preferred (In Network) Non-Preferred (Out of Network)* Calendar Year Deductible 1 Employee only $500 $1,500 Family (employee + one or more dependents) $1,500 $4,500 Out-of-Pocket Maximum For those that previously received their Form 1095-B in the mail, you can receive a copy of your Form 1095-B by going out to the Aetna Member Website in the "Message Center" under the "Letters and Communications" tab or by sending us a request at Aetna PO BOX 981206, El Paso, TX 79998-1206. 2021 - 2022 Medical Student & 2 Year MBA Student Voluntary Dependent Enrollment Form In order to enroll you must complete steps 1 through 6! you or your covered dependents while coverage is in effect. Dependent Coverage 16 a. July1, 2021: Summary Plan Description 1 Number: Plan Year: July 1 - June 30: 2 : Coverage for You and Your Dependents: 2021 City of Seattle - Benefits at a Glance (Employees with SPOG* Benefits Coverage) Eligibility: For new hires and dependents, coverage begins on your first day of employment if that date is the first calendar day of the month designated as a City business day or the first calendar day of the month designated or Family members can lose coverage for many reasons, such as growing up and leaving home. Suffix Account 3. Aetna will pay benefits for such claims to the custodial parent. Fiscal year 2021. Aetna Life Insurance Company. Coverage for insured dependents terminates in accordance with the Termination Provisions described in the Certificate of Coverage. An Individual Practice Plan with a High Deductible Health Plan (HDHP) Option and an Individual Practice Plan with a Consumer Driven Health Plan (CDHP) option This plan's health coverage qualifies as minimum essential coverage If you add a non-IRS dependent to your coverage, such as a Civil Union Partner, you will pay the difference between the 'One Dependent' rate and the ' Two Dependent' rate for that non-IRS dependent. Family members can lose coverage for many reasons, such as growing up and leaving home. Enrollment in order for your new coverage to be effective on January 1, 2021. Dependent coverage . Dependent children of VUMC couples can only be enrolled under Your coverage under the plan has a start and an end. 2. 1. 2021 City Traditional Plan* S.P.O.G Open Choice (PPO) Medical *Please note: In the attached document the effective date is 2020; however, this document represents the benefits for 2021 and minimal changes made to plan documents in 2021. All members and enrolled dependents have the same dental benefits available through Delta Dental. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 07/01/2021 - 06/30/2022 State of Delaware: Aetna CDH Gold Coverage for: Individual + Family | Plan Type: PPO For more information about limitations and exceptions, see the plan or policy document at www.HealthReformPlanSBC.com or by calling 1-877-542-3862. The benefits and provisions of the Plan as of January 1, 2021, are described in this Summary Plan Description (SPD). Arizona Board of Regents Student Health Insurance Plan administered by Aetna Student Health. Member Terminations 21 2. To learn more see the When coverage ends section. The Plan is underwritten by Aetna Life Insurance Company (Aetna). District of Columbia Public Schools | 2021 Page 10 of 44 41 $) 41 41 AFSCME (10-Month) Health Benefits Plan Premium Rates AETNA HEALTHCARE CONSUMER DRIVEN HEALTH PLAN (CDHP) Aetna CDHP Health Plan Summary TYPE ENROLLMENT CODE 2021 PREMIUM BI-WEEKLY 2021 PREMIUM MONTHLY Self-Only HM1 $ 41.61 $ 91.55 Self + 1 HM2 $ 81.79 $ 179.95 If you need to confirm coverage before you get . Contact Aetna Student Health at 877-261-8403 for assistance. D. ELIGIBLE DEPENDENTS TO BE COVERED / PRIMARY CARE PHYSICIAN SELECTION: *If you choose Aetna HMO coverage, you MUST include an Aetna in-network primary care physician (PCP) for yourself, spouse and all eligible dependents. Preferred Provider Organization (PPO) . Aetna HealthFund® HDHP and Aetna Direct Plan www.aetnafeds.com Customer service 888-238-6240 . 2021 Summary Plan Description. Emory University 2020-2021 Page 2 . AS Aetna HMO $177.00 $566.76 $222.00 $1,063.26 . Employer Name - Full Name of Organization 2. Critical Illness. 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