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«State of New Jersey        AETNA MEMBER HANDBOOK  Aetna Value HD Plan  Aetna Freedom Plan  ...»

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State of New Jersey 





Aetna Value HD Plan 

Aetna Freedom Plan 

Aetna Medicare Advantage PPO ESA Plan 







  Department of the Treasury  Division of Pensions and Benefits    PLAN YEAR 2015    BLANK PAGE Welcome!

Our goal is your good health. To achieve this goal, we encourage preventive care in addition to covering you when you are sick or injured. An extensive network of participating physicians and hospitals is available to provide you with easy access to medical care 24 hours a day, 7 days a week.

We believe that through the appropriate use of health resources, we can work together to keep you healthy and to control the rising costs of medical care for everyone.

Your Aetna Value HD and Aetna Freedom plan options are self-funded by the State of New Jersey and administered by Aetna Life Insurance Company (Aetna).

An online version of this handbook containing current updates is available for viewing over the Division of Pensions and Benefits website at www.state.nj.us/treasury/pensions/health-benefits.shtml.

Be sure to check the website for related forms, fact sheets, and news of any developments affecting the benefits provided under the State Health Benefits Program (SHBP) or the School Employees’ Health Benefits Program (SEHBP).

You can also check the custom Aetna website at www.aetnastatenj.com for medical and dental plan documents, discount program information and numerous other helpful resources.

Every effort has been made to ensure the accuracy of the Aetna Member Handbook, which describes the benefits provided and is an amendment to the contract with Aetna. However, State law and the New Jersey Administrative Code govern the SHBP and the SEHBP. If there are discrepancies between the information presented in this handbook and the law, regulations or contract, the latter will govern.

We wish you the best of health.

Your Member Handbook This member handbook is your guide to the benefits available through the Aetna Value HD and Aetna Freedom plans (referred to collectively in this handbook as the Plan). Please read the handbook carefully and refer to it when you need information about how the Plan works, what the Plan covers and how this Plan coordinates with other coverages you may have. It is also an excellent source for learning about many of the special programs available to you as an Aetna plan participant.

If you cannot find the answer to your question(s) in the member handbook, call the Member Services tollfree number shown on your ID card. A trained representative will be happy to help you.

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Aetna Value HD Plans: Overview

The Health Savings Account

Summary of Benefits: Aetna Value HD Plans

Aetna Freedom Plans: Overview

Summary of Benefits: Aetna Freedom Plans

How the Medical Plan Works

The Provider Network

The Primary Care Physician

It’s Your Choice

Provider Information

Key Terms

Sharing the Cost of Care


Your ID Card

Your Medical Benefits

Preventive Care

Vision and Hearing Services

Outpatient and Specialty Care

Short-Term Therapy

Family Planning


Hospital Care


Alternatives to Hospital Confinements

Outpatient Testing and Therapy

Durable Medical Equipment and Prosthetics

Behavioral Health

Emergency Care

What the Medical Plan Does Not Cover


Prescription Drug Program

Special Programs

Discount Programs

Health Management Programs

Disease Management Programs

Advanced Illness Resources

Transplant Support: The National Medical Excellence Program®


Active Employee Eligibility


Eligible Dependents

Medicare Coverage While Employed

Retiree Eligibility

When Coverage Begins

How You Pay for Coverage

When Coverage Ends

Termination of Employee Coverage

Termination of Dependent Coverage

Leaves of Absence

Portability of Coverage

Continuing Coverage

COBRA Continuation of Coverage

Continuation for Total Disability

Coordination With Other Plans

Effect of Another Plan on This Plan’s Benefits

Automobile-Related Injuries

Claims and Appeals

Claim Procedures


External Review

Administrative Appeals

Subrogation and Right of Recovery

Recovery of Overpayment

Legal Action

When You Need Help



Federal Notices

The Newborns’ and Mothers’ Health Protection Act

The Women’s Health and Cancer Rights Act

Health Insurance Portability and Accountability Act

Certification of Coverage

HIPAA Privacy


Aetna Value HD Plans: Overview The Aetna Value HD plans combine a point-of-service medical plan with a tax-favored health savings account that you can use to pay for qualified medical expenses. The funds in your HSA can pay for qualified medical expenses now (including the medical plan’s deductible) or accumulate over time to pay for future expenses.

There are two Aetna Value HD options:

• Aetna Value HD 1500

• Aetna Value HD 4000* * Local education active employees are not eligible for the Aetna Value HD 4000 plan.

The Health Savings Account You may be eligible to open a health savings account (HSA) when you enroll in an Aetna Value HD plan. The HSA is an interest-bearing account that works with the high deductible health plan to give you greater control over how you manage your health care spending.

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* Maximums are determined by the U.S. Treasury and subject to future cost-of-living adjustments.

Eligibility and Enrollment

To be eligible to open an HSA, you must be enrolled in an Aetna Value HD plan. You cannot open an HSA if:

• You are enrolled in or eligible for Medicare;

• You are covered by any other health care plan, including a Health Reimbursement Account or Flexible Spending Account; or

• You can be claimed as a dependent on someone else’s federal tax return.

Funding Your Account Your account is funded by pre-tax contributions you make through regular payroll deductions. The 2014

annual maximum for all contributions to your account is:

• $3,300 if you elect coverage for yourself only; or • $6,550 if you elect family coverage (“employee and spouse,” “employee and child” or “employee and family”).

The maximums are determined by the U.S. Treasury Department and subject to future cost-of-living adjustments.

If your payroll contributions are less than the annual maximum, you may choose to make up the difference at any point during the year by electronic fund transfer or by mailing a personal check to the address on the HSA deposit slip.

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Using the Funds in Your Account Qualified Expenses You can use your HSA to pay for qualified health care expenses, as defined by the Internal Revenue Service (IRS). Qualified medical expenses include your medical plan deductible and coinsurance payments. You can also use the HSA to pay for other qualified health-related care such as out-of-pocket dental and vision expenses. A complete list of HSA-qualified expenses can be found at www.irs.gov: click on Forms and Publications, then select IRS Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans, and IRS Publication 502, Medical and Dental Expenses.

Consult your tax advisor if you have questions about qualified expenses.

Payment Options

When you have qualified expenses, you have a choice to make:

• You can pay the expenses out of pocket and save your HSA funds for future qualified health expenses; or

• You can pay for the expenses using your HSA funds.

You will receive an HSA debit card in your HSA Welcome Kit when you first open your HSA. You can use your debit card to pay for qualified expenses from your HSA funds.

If you do not have your debit card with you when paying for qualified expenses and have to pay out of pocket, you can pay your provider online, right from your computer.

Save receipts from all transactions associated with HSA contributions and withdrawals for your tax records.

AutoDebit The AutoDebit feature allows you to have out-of-pocket medical expenses automatically withdrawn from your HSA to pay for your share of medical claims. AutoDebit is a convenient way to pay your share of medical care from HSA funds without using your HSA debit card or HSA checks.

Here’s how it works:

• You receive medical care from a physician or other health care provider.

• You or the provider submits a claim to Aetna.

• Aetna determines the appropriate amount of reimbursement for the doctor, as well as your share of the cost, based on the HDHP.

• Aetna withdraws funds directly from your HSA for qualified out-of-pocket expenses, up to your available balance.

• Aetna pays the provider using those funds.

Your doctor will bill you for any portion of your share of the cost that couldn’t be paid from your HSA balance.

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You should not elect the AutoDebit option if you want to use your HSA to save for future medical expenses.

Save for Future Health Care Expenses Your account can grow. Unused funds earn tax-free interest, with no minimum balance requirement. If you have money left in your account at the end of the year, it is rolled over to the following year and continues to accrue interest. Once your HSA accumulates $2,000, you may be able to take advantage of HSA investment services.

If You Change Plans or Leave Your Employer You own your HSA − if you change plans or terminate employment with the State of New Jersey, you don’t

lose the money in your account. You can:

• Leave the money in your current account. You won’t be able to make future contributions, but you can still use the funds to pay for qualified expenses or save them for future needs. A monthly account maintenance fee will be deducted automatically from your HSA balance.

• Transfer the balance in your account to another HSA trustee or custodian.

• Close the account and receive the remaining balance.

If you roll the balance into a new HSA within 60 days, there are no tax implications.

Taxes and penalties may apply if you do not roll the funds to another HSA within the 60-day window.

Tax Advantages Not only can you save money for the future, your HSA can help you save money on your taxes now!

• Contributions you make to your HSA through payroll deduction are made with pre-tax dollars. That lowers your taxable income, so you pay lower federal income taxes and Social Security taxes.

• If you make contributions to your HSA with a personal check, your contributions are tax-deductible because you are using after-tax dollars (money that has already been subject to income tax). You can take this tax credit above the line for post-tax contributions on your tax preparation form.

• The money you withdraw from your HSA to pay for qualified expenses is not subject to federal income tax.

• The interest earned on your HSA funds is not subject to federal income tax.

Consult your tax advisor if you have questions about the tax implications of HSA contributions.

Helpful Tools Aetna provides online resources to help you use your HSA and make decisions about health care. You can track your HSA activity online, 24/7, by logging in to your Aetna Navigator member website at www.aetnastatenj.com. For more information about Aetna Navigator, see When You Need Help.

You can also call Aetna Member Services at 1-877-782-8365 if you have any questions about your Aetna HSA.

3 Summary of Benefits: Aetna Value HD Summary of Benefits: Aetna Value HD Plans

Keep in mind:

• The Plan pays benefits only for care that is necessary.

• The deductible is the part of your covered expenses you pay before the Plan starts to pay benefits each year.

• The Plan’s coinsurance is the percentage of covered expenses that the Plan pays after you satisfy the Plan’s calendar year deductible. The coinsurance limit is the maximum you pay as your coinsurance share each year.

• The out-of-pocket maximum is the limit on the amount you pay for covered medical expenses out of your own pocket each year. It includes your medical plan deductible and your coinsurance.

• Network providers have agreed to charge no more than the negotiated charge for a service or supply that is covered by the Plan. You are not responsible for amounts that exceed the negotiated charge when you get care from a network provider.

• The Plan pays out-of-network benefits only for the part of a covered expense that is considered the recognized charge (formerly called the reasonable and customary limit).


If your out-of-network provider charges more than the recognized charge, you will be responsible for any expenses incurred that are above the recognized charge.

These charges do not apply to your deductible or out-of-pocket maximum.

• Precertification is a process that determines whether the services being recommended are covered by the Plan.

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