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Endowed Health

Aetna PPO Preferred Provider Organization (PPO) Plan

Aetna's DocFind Customized for Cornell

The Aetna PPO has an in-network benefit level and an out-of-network benefit level.

Each time you seek care, you can choose between two levels of coverage:

  • Preferred – care provided through Aetna's extensive network of participating providers
  • Non-preferred – care provided through a provider who is outside of the network (and you are responsible for precertification

When you receive care in-network:

  • No referrals are needed
  • You pay a $12 copay for office visits, and most services, after a $150 individual deductible
  • You have coverage for routine physicals and immunizations, as well as routine eye and hearing exams, all with a $12 copay
  • There are no reasonable and customary limitations
  • Emergency coverage – anytime, anywhere
  • There are no claim forms

With the Open Choice PPO plan, you’ll have open access to any provider-including specialists-without a referral. Whether you’re at home or away, open access means you have the freedom to go directly to the provider of your choice with no referrals necessary. Your benefit level will be determined according to your use of a participating or nonparticipating provider.

Aetna Open Choice PPO is designed to help you and your family obtain health care at a reasonable cost. It is very simple to use. The decision regarding which health care provider to see is an open one each time you need to see a provider. However, you’ll save money when you use providers who participate in the PPO network because you get higher, preferred benefit levels. If you decide to see a provider who is not participating in the PPO network, you will receive the plan’s non-preferred benefit level. Refer to the Endowed Health Plans Comparison Chart for 2008 . Medco Health Prescription Drug Coverage.

Simply present your ID card when seeking care through a participating provider. The provider will submit the claim to Aetna. Aetna will remit an Explanation of Benefits (EOB) to both you and the provider that will show your coinsurance and deductible responsibility.

Choosing a Preferred Provider
The provider directory is a good place to start. Your physicians may already participate with Aetna. You can also use DocFind – Aetna’s online provider directory to locate participating physicians based on geographical location, medical specialty and hospital affiliation.
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Make Your Choice with Confidence
From the prestigious university hospital to the local family doctor, the Aetna PPO plan offers you access to a wide range of preferred providers who must meet our credentialing standards. When a physician asks to join Aetna’s network, the physician’s licenses, education and work history are reviewed. In addition, a committee of practicing physicians, who also care for Aetna members, reviews information about the physician and the office. And then Aetna routinely reviews his/her credentials to make certain they continue to meet Aetna’s standards.
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Eligibility
You are eligible to participate in Aetna's PPO plan as of the day your employment begins if you are

  • a regular full-time staff member (appointed at least 35 hours per week for not less than six months) of the endowed colleges and units
  • a member of the faculty or academic staff of the endowed colleges (appointed at least one full semester at full-time)
  • a regular part-time staff member of the endowed colleges and units (appointed at least 20 - 34 hours per week) who will be appointed for at least six months; or for academic teaching staff, appointed at least one semester at half time.
  • a temporary staff member appointed initially for six months or longer; if the initial appointment (under six months) is extended past six months with no break in service, the effective date of coverage is based on the date the appointment is extended
  • a postdoctoral fellow or visiting fellow without salary in a contract college division of Cornell

If you are represented by a bargaining unit, your health care benefits are subject to the provisions of your particular bargaining agreement. Please refer to your labor agreement for details on participation.
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Who Is Eligible for Coverage?
Generally you, your spouse or same-sex partner and unmarried dependent children under age 19 are eligible for coverage. Dependent children include biological children, adopted children, and any other child you claim on your federal tax return who lives with you in a parent-child relationship. Coverage for unmarried dependent children may be extended to age 25 while they are full-time students. (Full-time is defined as 12 or more credit hours.) Coverage for mental or physically incapacitated children may also be continued, provided the disabling condition occurs while the child is a covered dependent, for as long as the dependent remains incapacitated.

A same-sex partnership is defined as two individuals of the same gender who live together in a long-term relationship of indefinite duration, with an exclusive mutual commitment in which the partners agree to be jointly responsible for each other's common welfare and to share financial obligations. If you wish to enroll your same-sex partner and/or partner's eligible child(ren), you and your partner need to sign and return a Statement of Same-Sex Partnership form to Benefit Services, 130 Day Hall.
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Imputed Income Assessed on Same-Sex Partners
The value of the health benefits your same-sex partner receives is viewed as taxable income based on the Internal Revenue Code (IRC). Same-sex partners do not meet the IRS's definition of a dependent. When the employer provides a benefit to someone other than a dependent (as defined by the IRC), the value of the benefit provided must be calculated into the gross income of the employee for tax purposes. Faculty and staff who cover a same-sex partner should be aware that this may increase their federal and state taxes.

The imputed income is the total amount Cornell contributes toward coverage, less the amount Cornell contributes for single coverage. The value is added in to your gross income biweekly or semi-monthly. The tax implications vary by individual and you may need to seek the advice of your tax advisor.

If you are currently enrolled in individual plus child(ren) coverage and you are adding your same-sex partner to your coverage, your imputed income is calculated on the value of the university's contribution for single coverage.

Your additional contribution for providing benefit coverage to your same-sex partner is the same as that charged for a spouse.  These amounts are deducted from your pay check on an after-tax basis.

Individual plus spouse/same-sex partner additional cost for 2008:

              24 pays             26 pays
               $96.52              $89.09

Individual plus spouse/same-sex partner plus child(ren):

             24 pays             26 pays
             $111.93              $103.32

Types of Coverage Available:

  • individual coverage: covers the faculty or staff member only;
  • individual plus child(ren) coverage: covers the faculty or staff member and his/her child or children;
  • individual plus spouse/same-sex partner and child(ren) coverage: covers the faculty or staff member, his/her spouse or same-sex partner, and their child or children;
  • dual eligibility.

Dual eligibility is a category available to an endowed staff or faculty member with dependent children whose spouse or same-sex partner is also a benefits-eligible staff or faculty member in an endowed unit of Cornell University. Only one employee enrolls for coverage and that employee covers all dependents, including the working spouse or same-sex partner. If you are covered within the dual-eligibility category, you must be sure to notify Benefit Services if you or your spouse or same-sex partner leave the employment of an endowed unit at Cornell. It is the responsibility of the employee to sign up for the dual eligibility rate.

It is not possible for dual-eligibility employees to cover each other or to both cover dependent children within the endowed health care program.
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Enrollment
Welcome to Cornell orientation sessions are scheduled for faculty and staff upon the initial employment at Cornell. The sessions are presented in a group setting and are designed to explain the benefits available to university employees. Each faculty and staff member are given enrollment materials to complete, which includes enrollment in the health care program.

You have 60 days to enroll for health care coverage by completing the enrollment materials and returning them to Benefit Services. You will have the opportunity to change your coverage during the fall annual enrollment for coverage effective the following January 1.
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Identification Cards. In approximately 14 days after you initially enroll, you should receive your health care identification card at your home address. Members will receive two ID cards listing their covered family members. You need to show it to your health care provider so that your claims can be properly handled. If you need additional cards, call Aetna’s Member Services at (877) 371-2007.
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Coverage Begins
Coverage starts for you when you begin employment, provided you are actively at work on that date. If you are disabled, or not actively at work on the date your coverage would be effective, your coverage begins after one complete day of active employment.
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Late Enrollment
A faculty or staff member who initially waives coverage and wishes to enroll at a later date must wait until the annual enrollment in the fall to enroll for coverage effective the following January 1. The exception to this would be if the faculty or staff member had a family status change.
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Coverage Changes:
Annual Enrollment
All eligible faculty and staff (including those who previously waived coverage) have the opportunity to enroll once a year during the annual enrollment period. Each employee receives a packet of information at his or her home address and has 31 days to return completed materials to Benefit Services.

New coverage selected during the annual enrollment period is effective the following January as long as no one seeking coverage is hospitalized on that date. If a member of your family is hospitalized, coverage is delayed for that individual until he or she is released from the hospital.
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Family Status Changes
It also possible to add or drop coverage for yourself or your family members ONLY if you experience one of the following family status changes and contact Benefit Services within 60 days of any of the following events:

  • marriage or divorce
  • birth or adoption (effective date placed for adoption) of a child
  • death of a spouse or child
  • termination or commencement of your (or your spouse's) employment
  • your spouse involuntarily loses eligibility for employer-provided health coverage or your spouse involuntarily gains coverage (e.g., your spouse's employer changes health coverage significantly or the eligibility requirements of the employer-provided health plan change to allow your spouse to be eligible for coverage)
  • enrollment, graduation or termination of full-time (defined as 12 credit hours) student status
  • qualifying for Medicare by you or your dependents
  • family medical leave

Section 125, the Internal Revenue Code and related regulations which govern certain aspects of the plan's operation prohibit employees from making a change in coverage during the year unless one of the family status changes outlined above occurs. Of course, you can always change your coverage election during the annual enrollment period each November. Changes made during the annual enrollment period are effective January 1 of the following year. Our plan is administered in this manner to comply with IRS regulations.

To add or drop coverage you need to complete an Open Choice enrollment form and return it to Benefit Services within 60 days of the status change. Changes not made within 60 days must wait until the annual enrollment period.
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Adding Coverage for Newborns
If you have single coverage at the time your child is born or adopted, you have 60 days to contact Benefit Services to add the child to your medical coverage and to change to a new coverage tier (individual plus spouse/same-sex partner, individual plus child(ren) or individual plus spouse/same-sex partner plus child(ren) (complete a "Cornell Endowed Aetna PPO form). Aetna will produce new ID cards reflecting family coverage in about 14 days.

A faculty or staff member with individual plus spouse/same-sex partner, individual plus child(ren) or individual plus spouse/same-sex partner plus child(ren) coverage must also contact Benefit Services and complete a new Cornell Endowed Aetna PPO form indicating "change" to add a new child (within 60 days).

Failure to add the newborn or adopted child within 60 days of birth or adoption will result in not being able to add the child to the Plan until the annual open enrollment period in November for coverage effective the following January 1.
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Cost of Coverage
In most cases, your share of the cost of health insurance coverage is deducted on a pre-tax basis directly from your paycheck. The cost of coverage depends on the coverage type you enroll in (individual, individual plus spouse/same-sex partner, individual plus child(ren) or individual plus spouse/same-sex partner plus child(ren)). In certain situations faculty and staff pay the full cost of coverage (e.g., leave of absence without pay, contract college postdoctoral fellows).

The cost, including the annual deductible and out-of-pocket maximum, is subject to change annually and depends in part on the claims experience of Cornell's faculty and staff and their families during the preceding year.

The Aetna PPO premiums for 2008 are listed below:

Type of Coverage Biweekly Semimonthly
Individual $22.24 $24.09
Individual plus child(ren) $100.22 $108.57
Individual plus spouse/ same-sex partner $111.33 $120.61
Individual plus spouse/ same-sex partner plus (child)ren $144.39 $156.42
Individual plus spouse/ same-sex partner working at Cornell (dual spouse*) plus child(ren) $75.08 $81.35

*Note: the dual spouse category is available to an endowed staff or faculty member with dependent child(ren) whose spouse or same-sex partner is also a benefits-eligible staff or faculty member in an endowed unit or Cornell University.
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Health Coverage
Regardless of whether you use a preferred or non-preferred provider, the Aetna PPO plan covers the same wide range of medically necessary services*:

  • Physician office visits
  • Hearing aids
  • Hospitalization and surgery
  • Diagnostic testing
  • Emergency care
  • Home health care
  • Maternity and newborn care
  • Durable medical equipment

Note: Mental Health and substance abuse benefits are managed and administered by ValueOptions. Please refer to the Behavioral Health benefits section of this communication. 

While Aetna PPO's network is extensive, there may be special circumstances when you need specialty care that is not available through a preferred provider. In such cases, your use of a non-preferred provider is reimbursed at 90% after the in-network deductible. If you have questions concerning this provision, call Aetna’s Member Services at (877) 371-2007.
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Emergencies
Medical emergencies are those whose symptoms could be perceived as life-threatening or as causing serious harm if not treated quickly. Emergencies are covered at the higher benefit level whether you use a preferred or non-preferred provider (paid at 90% after the deductible). However, non-emergency use of the emergency room is reimbursed at 50% after the deductible.
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Deductible
The deductible is the amount you will have to pay before the plan reimburses in a calendar year for eligible medical expenses. The deductible is $150 per individual ($400 non-preferred) and $300 per family ($800 non-preferred). The deductibles between the preferred and non-preferred benefits cross apply.
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Out-of-pocket Maximum
The out-of-pocket maximum is the most you will have to pay for eligible medical expenses in a calendar year. When your share of expenses, excluding copays, reaches $2,000 for an individual ($3,000 non-preferred) , or $4,000 for your entire family ($6,000 non-preferred), the plan pays $100% of eligible covered expenses for the rest of the calendar year for in-network expenses (excluding mental health and substance abuse).

The following charges are not eligible to be credited toward the out-of-pocket maximum: amounts you are penalized for failure to comply with the program's precertification requirements; copays, amounts above and beyond reasonable and customary charges; mental health and substance abuse benefits and items not covered under the plan.
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Reasonable and Customary (R&C)
In joining Aetna’s network, physicians and health care facilities have agreed to charge negotiated rates. They cannot balance bill. For additional information, refer to the Endowed Health Plans Comparison Chart for 2008 .

It is standard practice for insurance companies to set, within defined geographic areas, reasonable and customary limits for common medical procedures. Aetna obtains R&C information from the Health Insurance Association of America. If you seek care out-of-network, Aetna will reimburse at 80% after the deductible subject to R&C. You may actually pay more than the $4,000 individual out-of-pocket maximum.

For mental health and substance abuse benefits, please refer to the ValueOptions section of the Endowed Health Plans Comparison Chart for 2008 concerning R&C information.
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Centers of Excellence Program
Aetna’s Centers of Excellence Program recognizes how difficult it is for a patient/family who may be facing a complex medical procedure or transplant. As a patient needs arise for highly specialized procedures, certified case managers will work with the patient, family and physician in determining the most appropriate facility and physician as well as providing continuity of care. Aetna will provide access to care through their expanding network of healthcare providers identified as providing successful clinical outcomes.
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Sabbaticals and When You Travel
If you need non-emergency care away from home for a covered service, simply contact Aetna’s Member Services to locate a preferred provider in the area you are visiting or access Aetna’s provider directory. If you receive care from a non-preferred provider and Aetna did have participating providers, you will be covered at 80% after the preferred deductible. Non-emergency care received outside of the United States will be reimbursed at 90% after satisfaction of the preferred (in-network) deductible ($150/ individual, $300/ family).
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Coverage for Out-of-Area Dependents
Your dependent child(ren) who do not reside with you, but who meet the eligibility requirements, can be enrolled in the PPO plan which is available in 47 states. You can contact Aetna’s Member Services at (877) 371-2007 or check Aetna’s provider directory to locate a preferred provider in the area where they reside. If they receive care from a non-preferred provider, they will be covered at 80% after the preferred deductible.
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Three-Tier Prescription Drug Plan Administered by Medco $5/$20/$40
Prescription drugs are covered through Medco.
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Behavioral Health Benefits
ValueOptions administers benefits for the treatment of mental illness, alcoholism and drug abuse for Cornell’s Endowed Plan. ValueOptions is a leading provider of Managed Mental Health and Substance Abuse Programs. They have been managing the behavioral needs of over 20 million members associated with 50 Fortune 500 Firms, Government Agencies, Small and Middle-sized companies. Their national provider network includes more than 1,700 facilities and 40,000 licensed practitioners who are continuously evaluated to determine their ability to help.
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Inpatient Benefits
In order to receive in-network benefits, members must receive care from a provider participating in ValueOptions Network. To receive the in-network benefit level, you must contact ValueOptions at (800) 895-2799 prior to receiving care. Failure to meet medical necessity requirements may result in no coverage.

Inpatient mental health and substance abuse benefits are reimbursed at 90% up to 45 days per calendar year. No credit is given toward the medical out of pocket maximum. The inpatient calendar year maximum of 45 days is a combined limit for both mental health and substance abuse care received in-network and out-of-network. If you decide to seek care out-of-network, you will be reimbursed at 70% of reasonable and customary up to 45 days per calendar year combined total for in- and out-of-network visits.
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Outpatient Benefits
In-network, outpatient mental health and substance abuse benefits are reimbursed at 100% after a $12 copay (up to 50 visits per calendar year combined total for in- and out-of-network visits). Out-of-network, outpatient mental health and substance abuse benefits are reimbursed at 70% of reasonable and customary (up to 50 visits per calendar year combined total for in- and out-of-network visits). The outpatient calendar year maximum of 50 days is a combined limit for both mental health and substance abuse care received in-network and out-of-network.

All mental health and substance abuse benefits are reviewed for medical necessity. This means that the treatment and services are consistent with symptoms for proper diagnosis for the illness, disease or condition as determined by ValueOptions. In addition, ValueOptions will authorize the appropriate level of care that can be safely provided for the diagnosed condition in accordance with generally accepted psychiatric and mental health practices and the professional and technical standards adopted by ValueOptions.

If you seek care out-of-network, it is your responsibility to notify the provider of the need to confirm medical necessity with ValueOptions. You also need to be sure to tell your out-of-network provider that they must submit an Outpatient Treatment Report (OTR) to ValueOptions by the 10th visit in order for ValueOptions to authorize medically necessary outpatient care that may be required beyond the initial visits. If the OTR is not received by ValueOptions, ValueOptions may not authorize any additional benefits.
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Emergency Care
In an emergency, ValueOptions will arrange for a psychiatrist to meet you at the emergency room or direct you to a local facility for treatment. If you cannot call, or are in a life-threatening situation, go directly to an emergency room and notify ValueOptions within 72 hours of the treatment. If you do not call within 72 hours, benefits will be paid only for services received after you call. If you do not call at all, you will not receive any plan benefits.
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Filing Claims
ValueOptions processes claims for all mental health and substance abuse services. If you receive care from an in-network provider they are responsible for submitting all claims to ValueOptions. If you receive care from an out-of-etwork provider, you will need to file a claim to receive benefits by completing a standard HCFA claim form (available from your provider). Claims should be sent within 12 months of receiving treatment to:

ValueOptions
PO Box 1347
Latham, NY 12110-8847

If members have questions concerning benefits, claim inquires or the status of providers, members should call 1-800-895-2799 and a customer service representative can help answer their questions.
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Coordination of Benefits (COB)
The PPO Plan has a maintenance of benefits provision that provides payment up to the normal reimbursement level under the PPO Plan. When you or your covered family member has other group health care benefits available or if payment is made under a "no-fault" auto insurance policy, the maintenance of benefits provision takes effect.

This means that the combined payment from both sources will not exceed the amount the PPO Plan pays when there is no coordination with another plan. Under most circumstances, your combined reimbursement will total 90% and you will still have responsibility for the $12 copay until your out-of-pocket maximum has been reached. The prescription drug plan is a card program and is excluded from the maintenance of benefits provision.
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Coordination with No-fault Auto Insurance
In the case of a payment under the New York's "no-fault" auto insurance, the first $50,000 is paid by New York State. Any charges remaining are reimbursed, after deductible, at 90% until the out-of-pocket maximum is reached.
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Subrogation Provision
This provision prevents faculty/staff and covered family members from being reimbursed for medical bills both from PPO Plan and from a third party insurance company, in effect receiving a duplicate reimbursement.

For example, a subrogation right might exist when the PPO Plan has paid medical expenses for injuries and faculty/staff member suffered while helping a neighbor repair his or her roof. If the injured faculty/staff member receives a payment form a third party for medical expenses incurred as a result of the fall (for example, the neighbor's homeowner's policy), the PPO Plan is entitled to be reimbursed for all or part of the costs covered through Cornell's health care plan. In order to review possible subrogation situations, claims will be pended by PPO Plan until details are received explaining the nature of the accident.
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Order and Priority of Benefits
Under the COB provisions, you file your claim with the primary carrier first and then send copies of the same bills and your Explanation of Benefits to the secondary carrier for consideration.

A plan without coordination of benefits always pays first. If all plans have COB provisions, the order of payment is determined by the following:

  • the plan covering the person directly, rather than as a dependent, pays its benefits first
  • in the case of dependent children, the plan of the parent whose birthday occurs first in the calendar year will pay benefits first
  • in the case of a divorce or separation, the plan that covers the parent with financial responsibility for health care expenses, a qualified medical support order (QMCSO), or custody pays benefits first
  • the plan that has covered the person for the longer period of time shall be primary except if a retiree or laid-off worker goes to work for another employer. The plan of the current employer will pay benefits before the plan covering the individual (and family) as a retiree or laid-off employee.

If you are covered by more than one group health insurance plan and need assistance determining which plan should receive your bills first, call Aetna’s Member Services at (877) 371-2007.
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Continuation and Termination of Benefits:
When Coverage Ends
Unless you provide notification that you would like to continue health coverage, your current coverage will end at the end of the pay period in which you receive your last paycheck.
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Continuing Coverage
Faculty and staff and/or their eligible family members who are covered under the PPO Plan may continue medical coverage should one of the following situations occur (provided coverage is in effect on the date the event occurs):

  • family medical leave
  • death or total disability
  • divorce or legal separation
  • layoff of a covered employee
  • retirement prior to eligibility for Medicare
  • veterans called to active duty

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Family Medical Leave
Family Medical Leave entitles eligible faculty and staff to unpaid time away from work, up to total of 12 weeks during the fiscal year (July 1 - June 30). This is in accordance with the Family and Medical Leave Act (FMLA) of 1993. Contact Workers' Compensation/Disability Services or review the Human Resource Policy 6.9 Time Away from Work and related guidelines for full details about FMLA.

You may continue your existing health insurance coverage during an unpaid FML, (no use of accrued sick or vacation) and you will be billed by Records Administration. If you decide to terminate your health insurance coverage either at the start or during your FML, when you return from the leave, you have the right to have your health insurance reinstated, within 60 days, on the same terms as prior to the leave.

You may continue your existing health insurance coverage during FML provided you continue to pay for the employee share of the premiums. If you are taking an unpaid FML, (no use of accrued sick or vacation) you will be billed by Records Administration. If you decide to terminate your health insurance coverage either at the start or during the FML, when you return from the leave, you have the right to have your health insurance reinstated on the same terms as prior to the leave.
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Spouse, Same-Sex Partner and Dependent Coverage After Your Death
In the event that a covered employee or retiree dies, the surviving spouse/same-sex partner and any eligible covered dependent children may continue the health care plan until the surviving spouse remarries, the same-sex partner indicates that the exclusiveness of the former relationship has been made void, and/or the dependent children no longer qualify under the program definitions. The university contribution will continue and the surviving spouse or same-sex partner will be billed for any required employee or retiree contribution.
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Short Term Disability
A covered staff member who qualifies for short term disability benefits can continue the coverage in effect at the time the disability occurs until the disability ends. The university contribution will continue during the period of disability and the staff member will continue to have the health insurance premium deducted from the paycheck.
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Total Disability
A covered facility or staff member who qualifies for long term disability benefits can continue the coverage in effect at the time the disability occurs until the period of disability ends. The university contribution will continue during the period of disability and the faculty or staff member will be billed for any required contribution.
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Worker's Compensation
As a regular university faculty or staff member, you are eligible to continue certain benefits while you receive Worker's Compensation benefits. There is no change in your benefits as long as you continue to receive a Cornell paycheck. Normal health insurance deductions will be taken out of each check. However, once you are no longer receiving a paycheck from Cornell, endowed faculty and staff are billed on a quarterly basis for the employee cost of health insurance.

The university contribution will continue during the period of disability and the faculty or staff member will be billed for any required contribution.
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Divorce or Legal Separation
If you or your spouse decide to legally separate, you (and any eligible dependents) can continue coverage. However, your ex-spouse will no longer be eligible to continue coverage under your plan. Your ex-spouse will need to call Benefit Services at (607) 255-3936 to request a COBRA application to continue coverage within 60 days of the event or legal separation. The ex-spouse will be billed monthly, in advance, for up to 36 months.
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Qualified Medical Child Support Order
As a general rule, your plan benefits may not be assigned to another person. However, an exception exists in the case of a "qualified medical child support order". A qualified medical child support order is a court-ordered judgment, decree, order or property settlement agreement in connection with state domestic relations law that either:

  • creates or extends the rights of an "alternate recipient" to participate in a group health plan, including this plan; or
  • enforces certain laws relating to medical child support.

An "alternate recipient" is any child of a participant who is recognized by a medical child support order as having a right to enrollment under a participant's group health plan. A medical child support order must satisfy certain specific conditions to be qualified. The plan administrator will notify you if he or she receives a medical child support order that applies to you. You will also be notified of the plan's procedures for determining whether the medical child support order is qualified. The cost of our coverage depends on whether or not you elect individual or family coverage.
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Coverage During Layoff
Faculty or staff members who are no longer working because of a layoff or reduction in work force will continue this plan under COBRA. Completion of a COBRA application is required. The University contribution toward the cost of health coverage will continue for up to 12 months. If coverage is elected, you will be billed for the employee portion of the cost of your health plan. At the end of the 12 months, you will be billed the normal COBRA contribution rate for the remainder of your COBRA eligibility period.
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Position Leave
Employee's existing health insurance coverage will be maintained during the leave period provided they continue to pay both their share and the university's share of premiums (full cost).
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University Leave
Staff members who voluntarily resign their positions and are granted a University leave are eligible to continue this plan under COBRA. Employees will need to complete a COBRA enrollment form within 60 days of their University leave date to continue health coverage.
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Temporary Coverage Under COBRA
COBRA (Consolidated Omnibus Budget Reconciliation Act) is federal legislation which requires that employers make continuing health coverage available to employees who are no longer eligible for coverage based on the following situations:

  • termination of employment for reasons other than gross misconduct
  • reduction in work hours resulting in loss of eligibility for health coverage
  • a dependent child no longer meets the program's eligibility requirements.

The duration of COBRA coverage depends on the particular event that causes you or an eligible member of your family to lose coverage.
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18-Month COBRA Eligibility
If your employment terminates, your work hours are reduced or you are on a leave of absence, you and your covered dependents have the opportunity to subscribe for continuation of health coverage at group rates, for up to 18 months. You will automatically be notified of your eligibility to temporarily continue health coverage by the university. If you do elect to subscribe for coverage, you will be billed monthly, in advance for the full cost of this coverage (plus an additional 2% administrative fee).
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36-Month COBRA Eligibility
If your dependent loses eligibility for health coverage because he/she no longer meets the health program's definition of an eligible dependent or if you are divorced and your ex-spouse wishes to continue prior coverage, Benefit Services must be contacted within 60 days of the event. You will be sent a continuation application to be completed and returned to Benefit Services. The cost of COBRA coverage will be billed monthly, in advance, for up to 36 months.

It is your responsibility to initiate this contact with Benefit Services within 60 days. Employees are responsible for paying the full cost of COBRA coverage (plus and additional 2% administrative charge).

Failure to pay these charges within 30 days of the billing date will result in immediate termination of coverage.
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Sabbatical Leaves
Coverage continues provided you continue to pay the required premium, which continues to be deducted from your paycheck.
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Coverage Upon Retirement
Your coverage under the Cornell Health Care Program can be continue into retirement if you are at least age 55 when you retire and have at least 10 years of benefits-eligible service with Cornell University. Important: If you decide not to continue your health insurance at any time and cancel your coverage, you will not be able to re-enroll at a later date.

If you are not yet age 65 when you retire and are therefore, not eligible for Medicare, you have the opportunity to continue coverage under the health care program that is available to active employees. If you are covering a spouse/same-sex partner under the Plan who is retired and age 65 or older, they must enroll in Medicare Parts A & B. This also applies if your spouse/same sex-partner has been receiving Social Security Disability benefits and is eligible for Medicare. As a retiree, coverage under the 80/20 Plan provides for a limitation on benefits for you and your covered family members: private duty nursing is covered at 50% of eligible charges. Upon attainment of age 65, you will automatically be transferred to Cornell's 80/20 Plan for Retirees.

If you are 65 or older when you retire and are eligible for Medicare, you will receive coverage under the 80/20 Plan for Retirees.

An employee who retires and has not met the eligibility requirements for retiree medical coverage may be eligible to continue coverage under the COBRA provisions. If you retire before you turn 65 and are not eligible for Medicare, you can continue coverage for up to 18 months or until you are eligible for Medicare (whichever occurs first). Your family members also have the opportunity to continue health coverage for a period not to exceed 36 months from the date you retire or become eligible for Medicare.
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Filing Medical Claims
If you need help filing claims for services received out-of-network, or have questions you can call Aetna’s Member Services at (877) 371-2007 and a Member Services Representative will be happy to help you.

If your claim involves coordination of benefits with another insurance company, you must also include a copy of the explanation of benefits provided by the other company (including Medicare). Claims must be filed within 2 years from the date of service.

Medical benefits for any covered individual may be assigned to the hospital, doctor or other health care provider. When benefits are assigned, payment will be made directly to the health care providers.

Please note that this is a summary. Official benefits and conditions of coverage are contained in your contract. The complete terms of the programs are contained in the official plan document, which will govern in the case of discrepancy.
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