Cornell Program for Healthy Living

140 Pages·2015·0.97 MB·English

Cornell Program for Healthy Living Addendum – Effective January
1, 2016
Addendum to the Cornell Program for Healthy Living Plan (CPHL) Summary Plan
Description (SPD)
The information below is intended to serve as an update to the 2014 Cornell Program for Healthy
Living Plan (CPHL) Summary Plan Description (SPD)
Effective January 1, 2016
The medical and prescription drug copays apply to the out of pocket maximum for in-network
services.
The plan includes all of the preventive care benefits mandated by the ACA. Below are the items
revised or added for 2016:

• Eye exam (routine)-is now covered every year after copay
• Routine physical exam Age limit modified for CPHL: from age 19 changed to age 22 and up;
• Well Child age limit changed from birth to age 3 to birth to age 22
Preventive Care Covered at 100% In-network
Routine Physical Exams Family Planning – Tubal Ligation

Obesity Preventive Counseling Lactation Consultation

Tobacco Preventive Counseling Contraceptive drugs and devices (except those
covered by RX plan) including associated office
visit (i.e. IUDs).

Alcohol/Drug Abuse Counseling Breast Pumps and supplies

Preventive Lung Cancer Screening Contraceptive Consultation
Colorectal Cancer Screening (ie colonoscopy)
Routine PSA and DRE

Routine GYN and Pap Routine eye exam (includes pediatric) is covered at
100% every (instead of every year).
Routine mammography Prenatal care covered at 100% (delivery & nursery
care remain covered at 90%).

Breast Pumps and supplies OptumRx Prescription Drug Plan covers: Oral
Contraceptives, barrier methods, OTC
contraceptives, Plan B and ella (prescription
required).

Pre-natal maternity office visits OptumRx Prescription Drug Plan covers: Aspirin
products, iron supplements, Vitamin D, Folic Acid
& Prenatal Vitamins with prescription.
This is only a brief summary of the Plan Features. Please refer to the Summary of Benefits and
Plan Booklet for a complete description.
The Prescription Drug Plan is changing from Express Scripts (ESI) to OptumRx

• The copays are not changing and remain $5/$30/$50 for retail and $10/$60/$90 Home Delivery
in-network
• The drug formulary is changing
• Some medications are excluded
• Home Delivery of maintenance medications/specialty medications can be delivered to your home
address or new for 2016, you can direct the delivery to Gannett Health Center Pharmacy on the
Ithaca campus.
• Briova is the specialty pharmacy replacing ESI’s Accredo
• Aspirin products, iron supplements, Vitamin D, Folic Acid & Prenatal Vitamins with prescription
covered at $0 copay (in-network)

Effective April 1, 2015
Documentation Requirements Effective 4/1/15-copies only
Employee: Social Security Card (or ITIN-Individual Taxpayer Identification Number for non-
US Citizens).
You must provide copies of documents to support your dependent’s eligibility for coverage.
Spouse or Domestic Partner: Birth Certificate (or Visa/Passport accepted for non-US citizens),
Social Security Card (or ITIN-Individual Taxpayer Identification Number for non-US citizens),
Marriage Certificate, Domestic Partner Statement
Children (biological), stepchild, adopted: Birth Certificate (or Visa/Passport accepted for non-
US citizens), Social Security Card, ITIN (Individual Taxpayer Identification Number) for non-
US citizens, Proof of Disability, if applicable, Documentation establishing Paternity by Court
Order acknowledging Paternity. If your child is neither of the above, you must also complete the
Special Dependent Enrollment Form.
Effective January 1, 2015
Express Scripts Prescription Drug Plan Changes
Preferred Retail Pharmacy Network
You pay $5/$30/$50 copay at retail for up to a 30 day supply if you use pharmacies participating
in the Preferred Retail Pharmacy Network. Pharmacies include: Kinney, Rite Aid, Target,
Walmart, Wegmans, Quilans, Green Street Pharmacy, Gannett Student Health Center,
You pay $15/$40/$60, if you use CVS/Walgreens (Duane Reed), pharmacies not participating.
Aetna CPHL Addendum 1/1/16
Exclusionary Formulary: Certain medications that are available as generics or on the
formulary are no longer covered as of 1/1/15. Members can appeal and ESI will review the
clinical information provided by the physician.
Social Security’s Definition of a “Spouse”.
As of January 1, 2015, the Social Security’s definition of “spouse” has expanded to include a
same-sex spouse for the purpose of determining Medicare primacy. Therefore, an active
employee’s same-sex spouse, age 65 or older, will be Aetna primary not Medicare primary.

Certificates of Creditable Coverage (HIPAA Certs) No Longer Required

The Affordable Care Act prohibits the use of pre-existing condition clauses resulting in the need
to provide certificates of creditable coverage no longer necessary. On February 24, 2014, the
Treasury, the Department of Labor, and the Department of Health and Human Service jointly
issued final regulations which eliminated the requirement for plan sponsors to issue the
certificates after 12/31/14.

Grandfathered Health Plan Notice for January 1, 2015

Cornell University believes your plan is a “grandfathered health plan” under the Patient
Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable
Care Act, a grandfathered health plan can preserve certain basic health coverage that was already
in effect when that law was enacted. Being a grandfathered health plan means that your plan
may not include certain consumer protections of the Affordable Care Act that apply to other
plans, for example, the requirement for the provision of preventive health services without any
cost sharing. However, grandfathered health plans must comply with certain other consumer
protections in the Affordable Care Act, for example, the elimination of lifetime limits on
benefits.

Questions regarding which protections apply and which protections do not apply to a
grandfathered health plan and what might cause a plan to change from grandfathered health plan
status can be directed to your employer or Aetna member services using the phone number on
your member id card.

If your plan is governed by ERISA, you may also contact the Employee Benefits Security
Administration, U.S. Department of Labor at 1-866-444-3272 or
HUwww.dol.gov/ebsa/healthreformUH. This website has a table summarizing which protections
do and do not apply to grandfathered health plans. If your plan is a nonfederal governmental
plan, you may also contact the U.S. Department of Health and Human Services at
HUwww.healthreform.govUH.

Aetna CPHL Addendum 1/1/16
Schedule of Benefits

Employer: Cornell University

ASC: 397366

Issue Date: July 1, 2014
Effective Date: January 1, 2014
Schedule: 8A
Booklet Base: 8

For: Cornell Program for Healthy Living

This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional
information.

Aetna Choice POS II Medical Plan
CPHL ENHANCED
PLAN FEATURES WELLNESS AND IN- **OUT-OF-NETWORK
NETWORK

Calendar Year Deductible*

Individual Deductible* None $400

Family Deductible* None $800
Once family deductible is met, all
family members will be considered
as having met their deductible for
the remainder of the Calendar Year

* Unless otherwise indicated, any applicable deductible must be met before benefits are paid.
** Subject to Recognized Charge

The Maximum Out of Pocket Limit includes plan deductible.

The Maximum Out of Pocket Limit excludes precertification penalties, copayments, expenses paid at 50%,
non-covered expenses and charges over the recognized charge.

Individual Maximum Out of Pocket Limit:

 For network expenses: $2,000.
 For out-of-network expenses: $3,500.

Family Maximum Out of Pocket Limit:

 For network expenses: $4,000.
 For out-of-network expenses: $7,000.

Lifetime Maximum Benefit per Person Unlimited Unlimited

1
How the Cornell Program for Healthy Living Works

The Cornell Program for Healthy Living (CPHL) is a new comprehensive health plan that encourages and facilitates your progress
to healthier living. This is achieved by focusing on your total health through an Enhanced Wellness Program. There are two
components: the underlying Medical Plan and the Enhanced Wellness Program.

Highlights of the Medical Plan (Choice POSII)

In-Network Out-of-Network
Level of Health Plan Support Higher so you pay less out of pocket: Lower so you pay more out of pocket:
No Deductible $400 deductible
$20 office visit copay 80% thereafter
90% for other services
Pharmacy is administered by Express Pharmacy is administered by Express
Scripts/Medco. Scripts/Medco.

PCP Requirement Applies to enhanced wellness benefit only N/A
(see back page for details).

Referral Requirement to a Specialist No referrals needed. No referrals needed.

Preventive Care Covered at 100%, regardless of where you Covered at 80% after deductible.
live and the network PCP you choose.

Broad National Network of Fully available at discount prices. You may use out-of-network
Physicians and Hospitals providers but it will cost you more.

Balance Billing Providers have agreed not to bill you over Providers are free to bill you over the
(the amount billed by your provider that is allowed amount. allowed amount.
over the insurance company’s allowed
amount)

Certification for Inpatient Hospital Participating provider precertifies for you. You precertify by calling the toll-free
and Other Medical Services number on your ID card. Failure to
precertify may result in substantially
reduced benefits.

Claim Forms to File No. Yes.

2
The Enhanced Wellness Program

The Enhanced Wellness Benefits are available only if you chose to utilize a PCP from a select list of Ithaca based In-
Network Providers. Please note: there is NO PCP selection required if you and your family members elect not to take part
in the Enhanced Wellness Exam and related services.

Step 1 All covered family members, including children, must select a PCP from a select list of Ithaca
To Receive an Enhanced based In-Network providers if you would like to take advantage of the Enhanced Wellness
Wellness Exam Program. These PCPs have committed to support this plan and a play a pivotal role in helping
Select a PCP you reach your wellness goals for the year. You can select your PCP at the time of enrollment
through Benefit Services, or after enrollment through Aetna Navigator or by calling Aetna
Member Services at 1-877-371-2007. You can find the names of the Ithaca based PCP’s at
https://www.hr.cornell.edu/benefits/health/cphl_directory.pdf.

Step 2 You and your enrolled adult family members (spouse, domestic partner and children ages 1and
Schedule Physical Exam over) schedule annual comprehensive physical exam(s) and lab work with your Enhanced
and Lab Work Wellness PCP unless otherwise directed by your PCP. Your comprehensive exam and routine
lab work are covered at 100%.

Step 3 You and your enrolled adult family members (spouse, domestic partner and children ages 18
Complete a Sustainable and over) will complete a Sustainable Health Questionnaire (SHQ)/Health Risk Assessment
Health Questionnaire (HRA) once a year. This SHQ/HRA must be completed no more than one week prior to your
SHQ/HRA annual comprehensive physical exam with your PCP. Children age 1 through 17 will complete
a pediatric assessment in their PCP’s office.

Step 4 Once you have completed your SHQ/HRA, you are ready for a comprehensive physical exam
Comprehensive Exam and a review of your SHQ results with your Enhanced Wellness PCP. There is no cost to you.
and Wellness Report Once the exam and review have been completed, your PCP will provide you with an Annual
Wellness Report from which you and your PCP will develop a healthy living action plan.

Step 5 Your Wellness Report and healthy living action plan may include referrals to local resources, or
The Healthy Living to additional services within your PCP’s office, to assist you in achieving your goals. These
Wellness Resources additional services for smoking cessation, nutritional counseling and diabetic education are
covered at 100%. In addition, if you have medical complications or need special attention, your
PCP may refer you to the Cayuga Center for Healthy Living (CCHL) for advanced wellness
counseling and support for the following services. The costs for these services at CCHL are

 Health Behavior Assessment $20 copay
 Health Risk Assessment Interpretation $20 copay
 Medically Supervised Exercise $20 copay
 Team Conference $20 copay
 Preventive Medical Counseling $20 copay
 Stress Management $20 copay

Faculty and Staff are also eligible to receive a $15 monthly discount from either the Ithaca
YMCA, Island Fitness or the Cornell Wellness Program (the discount makes the Cornell
Wellness free). Spouses and domestic partners who are Cornell employees are eligible if they
are covered under CPHL. The CPHL Aetna ID Card and Cornell ID are required to be
presented to the fitness centers to confirm eligibility for the discount.

Step 6 Following your Enhanced Wellness exam, your PCP may decide to have you return for up to 3
Follow-up Visits monitoring or counseling check-ups during the year. These extra visits are also covered at
100% under the Enhanced Wellness benefit.

You are strongly encouraged to see your Enhanced Wellness PCP at least once every year to
complete steps 2-5 above unless otherwise directed by your PCP.

3
Payment Percentages listed in the Schedule below reflects the Plan Payment Percentage. This is the amount
Aetna pays. You are responsible to pay any deductibles, copayments, and the remaining payment percentage.
You are responsible for full payment of any non-covered expenses you incur.

Covered Expenses That Are Subject To The Calendar Year Deductible Are Noted In The Schedule Below.

* The In-Network benefit level includes medically necessary care provided out of the country.

CPHL ENHANCED
PLAN FEATURES IN-NETWORK* OUT-OF-NETWORK
WELLNESS
Wellness Benefit
Routine Physical Exams 100% including lab and 100% including lab and 80% per exam after
Adults only. x-ray x-ray Calendar Year deductible
Includes coverage for
immunizations.

Maximum Exams per Calendar
Year

Adults age 18 and over 1 exam plus 3 follow up 1 exam 1 exam
preventive visits

Well Child Exams 100% including lab and 100% including lab and 80% per exam after
Includes coverage for x-ray x-ray Calendar Year deductible
immunizations

Maximum Exams
Under age 3
first 12 months of life 7 exams 7 exams 7 exams
th th
13 – 24 months of life 4 exams 3 exams 3 exams
th th
25 – 36 months of life 4 exams 3 exams 3 exams

For age 3 to 18 4 exams 1 exam 1 exam
Immunizations Same as In-Network 100% 80% per visit after
when not part of the Calendar Year deductible
physical exam

Screening & Counseling 100% per visit 100% per visit 80% per visit after
Services - Obesity, Misuse of Calendar Year deductible
Alcohol and/or Drugs &
Use of Tobacco Products

Nutritional Counseling 100% per visit $20 per visit copay then 80% per visit after
other than Screening & the plan pays 100% Calendar Year deductible
Counseling Services for in an office setting;
Obesity otherwise 90%

4
Obesity
Maximum Visits per Unlimited 26 visits (however, of these 26 visits (however, of these
Calendar Year only 10 visits will be only 10 visits will be
(This maximum applies only to allowed under the Plan for allowed under the Plan for
Covered Persons ages 18 and older.) healthy diet counseling healthy diet counseling
provided in connection with provided in connection with
Hyperlipidemia (high Hyperlipidemia (high
cholesterol) and other cholesterol) and other
known risk factors for known risk factors for
cardiovascular and cardiovascular and
diet-related chronic disease* diet-related chronic disease*

*Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit.

Nutritional Counseling other than
for Obesity
Maximum Visits per Unlimited Based on Medical Based on Medical
Calendar Year Necessity Necessity

Use of Tobacco Products
Maximum Visits per Calendar Unlimited 8 visits* 8 visits*
Year

*Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit.

Misuse of Alcohol and/or Drugs
Maximum Visits per Calendar Unlimited 5 visits* 5 visits*
Year

*Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit.

CPHL ENHANCED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK
WELLNESS
Routine Cancer Screenings
Routine Mammography Same as In-Network 100% 80% per test after
Calendar Year deductible

Maximum 1 test 1 test 1 test
tests per Calendar Year

Prostate Specific Antigen 100% per test 100% 80% per test after
Test Calendar Year deductible
For covered males age 40 and
over.

Maximum tests per Calendar 1 test 1 test 1 test
Year

5
Routine Digital Rectal 100% per test 100% 80% per test after
Exam Calendar Year deductible
For covered males age 40 and
over.

Maximum tests per Calendar 1 test 1 test 1 test
Year

Fecal Occult Blood Test Same as In-Network 100% 80% per test after
Calendar Year deductible

Maximum tests per Calendar 1 test 1 test 1 test
Year

Sigmoidoscopy Same as In-Network 100% 80% per test after
Age 50 and over Calendar Year deductible

Maximum Tests per 5 1 test 1 test 1 test
consecutive year period

Double Contrast Barium Same as In-Network 100% 80% per test after
Enema (DCBE) Calendar Year deductible
Age 50 and over

Maximum Tests per 5 1 test 1 test 1 test
consecutive year period

Colonoscopy 1 test 100% 80% per test after
age 50 and over Calendar Year deductible

Maximum Tests per 10 1 test 1 test 1 test
consecutive year period

6
All Other Routine Exams Same as In-Network 100% 80% per test after
and Screenings Calendar Year deductible

Maximum Subject to any age and Same Same
per Calendar Year visit limits provide for in
the current
recommendations of the
United States Preventive
Services Task Force and
comprehensive guidelines
supported by the Health
Resources and Services
Administration

For details, contact your
physician, log onto the Aetna
website www.aetna.com, or call
the number on the back of your
ID card.

CPHL ENHANCED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK
WELLNESS
Well Woman Preventive Visits
Routine Gynecological Same as In-Network 100% 80% per exam / test after
Exam (Including Routine Calendar Year deductible
Pap Smears)

Maximum 1 exam 1 exam 1 exam
per Calendar Year

Prenatal Visits Same as In-Network 100% 80% per exam after
Calendar Year deductible

CPHL ENHANCED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK
WELLNESS
Comprehensive Lactation Support and Counseling Services
Lactation Consultation Same as In-Network 100% for the first 6 visits 80% per visit after
per year. $20 copay Calendar Year deductible
thereafter

Breast Pump and Supplies Same as In-Network 100% 80% after Calendar Year
Electric Breast Pump 1 service deductible
maximum in 36 months

7