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Endowed Health

80/20 Summary Plan Description

You are eligible to participate in this 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 position at 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.

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 Internal Revenue Service'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. Please refer to the Endowed Same-Sex Partners Questions & Answers for more information.

If you are currently enrolled in employee plus child(ren) coverage and 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 rates for 2009:

              24 pays             26 pays
               $132.21              $122.03

Individual plus spouse/same-sex partner plus child(ren) rates for 2009:

             24 pays             26 pays
             $194.45            $179.49

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 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 (WTC) sessions are scheduled for faculty and staff upon 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 from your hire date 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 four weeks after you initially enroll, you should receive your health care identification card (two per family) at your home address.

If you need additional cards, you can order additional cards by calling Aetna at (877) 371-2007.
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Coverage Begins
Coverage begins 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 and Family Status 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 must return completed materials to Benefit Services by the Open Enrollment deadline.

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 :

  • 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 of 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 80/20 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 child is born or adopted, you will have 60 days to contact Benefit Services to add that child to your medical coverage and to change to a new tier coverage (e.g., employee plus child(ren). A faculty or staff member with employee plus spouse, employee plus spouse/same-sex partner, employee plus child(ren) coverage must also complete Endowed 80/20 Plan enrollment materials indicating "change" to add a new child (within 60 days) so that health claims for that child can be processed. It is important that you remember to add your new dependent so that processing and reimbursement of claims for your new child will not be delayed.
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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 whether you enroll in single or family coverage. In certain situations faculty and staff pay the full cost of coverage (e.g., leaves of absence without pay and 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 80/20 Plan 2009 rates are listed below:

Type of Coverage Biweekly Semimonthly
Individual $30.47 $33.01
Individual plus child(ren) $137.13 $148.56
Individual plus spouse/ same-sex partner $152.50 $165.22
Individual plus spouse/ same-sex partner plus (child)ren $209.96 $227.46
Individual plus spouse/ same-sex partner working at Cornell (dual spouse*) plus child(ren) $109.18 $118.28

*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
In general, the Plan reimburses medically necessary services and supplies at 80% after satisfaction of the annual deductible of $400 individual ($800 per family). The deductible is based on a calendar year. Once you have met the $400 annual deductible, the plan reimburses at 80% and you are responsible for the remaining 20%. Once you have paid $3,000 in individual out-of-pocket expenses ($6,000 per family), the plan reimburses at 100% of reasonable and customary (R&C) charges.

Reasonable and customary charges (R&C) are the prevailing fees based on the Health Insurance Association of America's data for medical services and supplies. When you submit a claim, Cornell's health claims administrator will review the charges and provide the reimbursement based on the R&C limits for necessary medical services. R&C charges are what 80% of physicians charge within a defined zip code area for a specific procedure. Charges above the R&C limits are not covered and do not apply toward your annual out-of-pocket maximum.

To determine whether your physician's charges are within R&C limits, call Aetna's Member Services at (877) 371-2007 with the nine digit diagnostic code for the procedure you will undergo and the amount your physician will charge.
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Coverage for Routine Physical Exams
Routine physical exams are covered for employees only. They are reimbursed at 80% and are not applied to the deductible. Employees under age 40 receive reimbursement at 80% up to $150 every other year. Employees age 40 and over receive reimbursement at 80% up to $250 every other year.
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Coverage for Hearing
Routine hearing exams: the Plan reimburses at 80% of R&C one exam every 24 months for all members.

Hearing aid equipment:
Adults and children age 13 and older: reimbursed at $1,500 per hearing aid per ear, once every four years.
Children age 12 and under: reimbursed at 80% up to $1,500 per hearing aid per ear, once every two years.

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Well Baby Care
Well Baby Care is reimbursed at 80% without meeting a deductible. Children are eligible up to age 3. Reimbursement is limited to $200 annually per child.
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Mammograms
Routine mammograms are reimbursed at 80%; not subject to deductible. Age related: women age 35 - 40 reimbursed for one; age 40 - 49 reimbursed for one every other year; age 50 or above reimbursed every year.
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Mental Health Services
The plan covers inpatient medically necessary stays at 80% up to 50 days per calendar year. The $3,000 out-of-pocket maximum does not apply.

Outpatient mental health is reimbursed at 50% up to 20 visits or 40 visits per calendar year following inpatient treatment. No credit toward the out-of-pocket limit. Providers must meet state licensing requirements and be recognized by Aetna. You can call Aetna at (877) 371-2007 to verify that your provider is recognized by Aetna.
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Expenses for Treatment of Substance Abuse
Treatment of substance abuse is eligible for reimbursement when diagnosed by a physician. The resulting plan of treatment must establish a prescribed program of therapy supervised by a physician, including follow-up therapy directed by a physician.

Confinement in a hospital for inpatient treatment of substance abuse or treatment of the medical complications associated with substance abuse is covered as any other hospitalization; charges approved for reimbursement will be covered at 80% (after satisfaction of the annual deductible), as long as you have pre-certified the hospital stay.

Confinement in an approved alcoholism or drug treatment facility is covered for the first 45 days of full-time confinement in any one period of illness. The program's coverage reimburses up to 80% of approved charges (after deductible), as long as your stay has been pre-certified. These benefits will be reduced by any days of hospital confinement (for example, a hospital-based detoxification program).

The program also provides coverage for outpatient treatment of substance abuse. Charges for counseling or effective treatment services furnished on an outpatient basis by a physician, hospital or treatment facility are eligible for reimbursement at 80% after the annual deductible has been satisfied. Coverage is limited to no more than 60 visits per calendar year, and up to 20 of the 60 visits may be counseling expense incurred by your covered dependents, provided the counseling is directly related to the alcoholism or substance abuse.

You should also be aware Cornell University makes an Employee Assistance Program (EAP) available to faculty and staff experiencing personal or family problems, including substance abuse. By calling (607) 273-1129, you can talk with a qualified professional and receive referrals for community-based treatment.
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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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Hospital Expenses
Eligible hospital expenses are reimbursed at 80% after the deductible is satisfied if the necessary contact is made with Aetna. Failure to precertify inpatient hospital stays will result in a penalty and a lower reimbursement.

Charges eligible for reimbursement include a semi-private room and board charges, intensive care unit charges and additional medically necessary services and supplies.
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Surgical Expenses
Inpatient and outpatient surgical expenses are eligible for reimbursement at 80% (subject to R&C) after your deductible is satisfied. Covered expenses include: pre-operative and aftercare for covered surgical procedure required for treatment of diseases, injuries, fractures and dislocations, regardless of where the treatment is provided.
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Precertification for Overnight Hospital Stays Required
The 80/20 Plan requires that non-emergency overnight hospital stays receive pre-admission certification by calling Aetna's Member Services at (877) 371-2007. If you know that you or one of your covered family members are going to be hospitalized overnight, you need to contact Healthline before the admission. If this required contact is not made, all covered expenses will be reimbursed at 50% (up to a maximum of $1,000) and these unpaid expenses do not count toward your out-of-pocket maximum.
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Emergency Admissions
If you or an eligible member of your family is admitted to the hospital on an emergency basis, contact Aetna's Member Services within 48 hours or on the next business day following admission to avoid a precertification penalty mentioned above.
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Second Surgical Opinions
Second Surgical Opinions are not required for any medically necessary procedure or treatment. You are encouraged to seek a second surgical opinion as a means of self-protection. A second opinion by a board-certified surgeon may make you aware of alternative methods of treatment for your particular condition or provide additional information. The final decision is always yours to make.
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Same-Day Surgery/Outpatient Surgery
It is now possible to have many non-emergency surgical procedures performed in your doctor's office, in an ambulatory surgical facility, or on an outpatient basis. You do not need to call Aetna to precertify procedures that are routinely performed in an outpatient setting as standard practice by medical professionals.

If you or your eligible family member are hospitalized for a procedure which is routinely performed on an outpatient basis, the cost of your overnight hospital stay is not eligible for reimbursement except in some cases. For instance, if you have a medical condition (such as a cardiac problem) that necessitates hospitalization for a procedure that can normally be performed safely on an outpatient basis, your hospital stay can be pre-certified in advance if your attending physician provides documentation that hospitalization is necessary due to a medical condition which places you at risk for outpatient surgery. By calling Aetna at (877) 371-2007 you can find out how to submit the required documentation.
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Medical Case Management
Aetna provides nurses to provide case management services for you. If you experience a prolonged illness or hospitalization, this nurse will serve as your advocate, making sure that the treatment provided to you or your family members is properly coordinated and that all options are explored and explained to you and your family. Through case management and discharge planning, it may be possible for you or your family member to recuperate in the comfort and security of your own home with supportive services from home health care agencies or other alternative arrangements.
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Institutes of Excellence
Aetna has designated certain hospitals as Institutes of Excellence for their expertise in certain highly intensive, specialized procedures such as heart, lung, liver, kidney, and pancreas transplants. These hospitals were chosen on the basis of their experience and outcomes with transplants, their continuity of follow-up care and ongoing review and reporting to Aetna Plans.

If you should need one of these procedures, working with your physician, you can choose to go to one of these Institutes of Excellence.

The Institutes of Excellence offer:

  • special access to medical institutions recognized for excellence in certain technically advanced procedures;
  • negotiated rates;
  • comprehensive case management that include special attention to the needs of patients and their families, including travel and accommodation expenses associated with the transplant for the patient and one companion, up to $10,000. Aetna's corporate travel department will make travel arrangements, and lodging will be coordinated by the regional clinical specialist and the hospital.

You can call Aetna's Member Services at (877) 371-2007 for the names of hospitals that currently participate.
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National Cardiac Care Program (NCCP)
Aetna has designed institutions recognized in the field of cardiovascular surgery. These institutions have been selected to participate in the National Cardiac Care Program based on Aetna's evaluation of four critical factors:

  • sufficient experience (volume) in the performance of identified cardiovascular procedures;
  • demonstrated excellence in achieving successful clinical outcomes;
  • appropriate patient selection criteria;
  • institutional efficiency as demonstrated by favorable pricing.

The cardiovascular procedures currently utilized under the NCCP are cardiac catherization, by-pass surgery, angioplasty and valve replacement.

Faculty and staff can work with their physician and an Aetna nurse at (877) 371-2007 for a referral to an institute. Not all cardiologists and cardiac surgeons at National Cardiac Care Program facilities participate in the program. The NCCP program is separate and distant from the Institutes of Excellence Program. Aetna does not cover the costs associated with travel or lodging or assist in making travel arrangements.
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Alternatives to Hospital Care

Home Health Care
After you pay the deductible, the 80/20 Plan pays 80% of covered charges provided under an approved home health care plan for up to 120 visits per calendar year by an approved home health care agency. The care provided must be in lieu of an inpatient hospital confinement. Previous hospitalization is not required. Each four-hour period of home health aide services is considered one visit.

Covered charges include a part-time or intermittent nursing care by or under the supervision of a registered nurse, and could also include physical, occupational or speech therapy if prescribed by a physician. Eligible expenses for home health aide services, necessary medical equipment and other supplies that are medically necessary and which require a prescription by a physician will be covered. Custodial care is not covered.
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Skilled Nursing Facilities
The 80/20 Plan covers treatment provided in an approved skilled nursing facility at 80% after the deductible has been met. To qualify for this coverage you must have been hospitalized for at least three days, then confined in a skilled nursing facility within 14 days of discharge from the hospital. Confinement must be medically necessary as certified by your attending physician.

Custodial care, services and supplies furnished mainly to assist a person in maintaining the skills of daily living are not eligible for reimbursement under this or any other provision of the health care program.
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Hospice Care
A hospice is a public or private organization that provides care and services for terminally ill patients. A person is considered terminally ill if he or she is expected to live six months or less.

Inpatient hospice benefits are payable for up to 30 days of confinement during the terminally ill patient's lifetime when provided as part of a physician's written, approved hospice care program. Covered charges include treatment for pain control and other acute and chronic symptom management.

Hospice care can also be provided in an outpatient setting. Services provided by a hospice care agency are eligible for reimbursement at 80%, after deductible, up to a lifetime maximum of $3,000. Charges eligible for reimbursement include up to eight hours daily of part-time intermittent nursing care provided by an RN or LPN or up to eight hours daily of part-time or intermittent home health aide services. Medical supplies, drugs, and medicines prescribed by your physician, medical social services under the direction of your physician, charges for therapy provided by physical or occupational therapists or charges by physicians for consultation or case management services are also covered.
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Other Medical Services and Supplies
After you satisfy the annual deductible, the 80/20 Plan pays up to 80% (100% after the out-of-pocket maximum is reached) of reasonable and customary charges for the following medically necessary services and supplies:

  • private nursing charges by a registered or licensed practical nurse;
  • doctor's office visits for treatment of illness or injury;
  • diagnostic expenses, including costs for x-rays and laboratory tests as well as physician's fees for interpretation;
  • maternity expenses are covered the same way that expenses for any illness or injury are covered. Charges, including those for a birthing center and certified nurse midwife, are covered when incurred. The baby's room and board charges are included in the mother's charges;
  • services provided by a licensed chiropractor, subject to medical necessity review;
  • allergy serums;
  • services provided by a licensed podiatrist for diagnosis, treatment and surgery;
  • speech therapy when performed by a qualified speech therapist to restore speech to an individual who has lost an existing speech function as the result of a disease or injury;
  • treatment provided by a physiotherapist or an occupational therapist;
  • artificially assisted fertilization $20,000 lifetime limit "per family";
  • dental care for treatment of injury to the jaw or natural teeth is covered for up to one year from the date the accident occurs. Removal of up to four unerupted, impacted wisdom teeth is also covered;
  • miscellaneous services and supplies including the following when they are considered necessary medical care or treatment: X-rays, radium and isotope therapy; anesthetics and their administration; medical and surgical equipment rental; casts, splints, trusses, braces, crutches and surgical dressings; blood and blood plasma; artificial limbs and eyes; and ambulance services.

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Exclusions and Limitations
All medical treatment, services and supplies must be necessary and prescribed by a legally licensed physician. However, certain treatments or services will not be considered. Reimbursement is not provided for the following expenses:

  • charges related to a service, supply or treatment that is not generally accepted by the medical profession, or that is deemed to be experimental or for purposes of research;
  • expenses for treatment neither the covered individual or any other person has a legal obligation to pay;
  • charges for custodial care, which is rendered to a patient primarily for the purpose of meeting personal needs to support the essentials of daily living;
  • treatment of temporomandibular joint dysfunction (TMJ), except for diagnostic purposes or in regard to medically necessary oral surgery. Examples of services/supplies not covered are therapy, occlusal equibration, or rehabilitation orthodontics such as charges for appliances used to alter occlusion and/or reposition the lower jaw, whether or not the purpose of such service or supply is to relieve pain;
  • dental work, unless it is required because of an accident (within 12 months) to natural healthy teeth in good repair;
  • occupational illness or injuries which are covered by Worker's Compensation;
  • expenses incurred on account of war, or for services, supplies and treatment provided or covered under any governmental plan or law;
  • services in connection with cosmetic surgery except for reconstructive surgery due to disease or injury; other surgery for the prompt repair of an injury that occurs while the person is covered; or a congenital abnormality that causes a functional defect in a dependent child;
  • charges for education, special education or job training, unless given in a facility that also is providing medical or psychiatric treatment;
  • hearing aids, routine eye exams or eye glasses, except for temporary and/or initial permanent corrective lenses needed following a cataract operation;
  • charges for or related to artificial insemination, or embryo transfer procedures;
  • charges for acupuncture therapy, except for acupuncture performed by a physician as a form of anesthesia in connection with surgery that is covered under this program.

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Coordination of Benefits (COB)
The 80/20 Plan has a maintenance of benefits provision that provides payment up to the normal reimbursement level under the 80/20 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 80/20 Plan pays when there is no coordination with another plan. Under most circumstances, your combined reimbursement will total 80% and you will still have responsibility for the remaining 20% 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 80% 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 Aetna and from a third party insurance company, in effect receiving a duplicate reimbursement.

For example, a subrogation right might exist when the Endowed Health 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 from a third party for medical expenses incurred as a result of the fall (for example, the neighbor's homeowner's policy), the Endowed Health 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 Aetna 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 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 payperiod in which you receive your last paycheck. A special provision applies to faculty/staff hired before July 7, 1983. If you were hired prior to July 7, 1983 and have been continuously employed, you will receive coverage for 31 days following your date of termination.
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Continuing Coverage
Faculty and staff and/or their eligible family members who are covered under the 80/20 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 (FML) 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 Family Medical Leave.

You may continue your existing health insurance coverage during an unpaid FML (no use of accrued sick or vacation leave) 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.
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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 faculty 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 if 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 as of the date of divorce. 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 divorce or legal separation. The ex-spouse will be billed monthly for COBRA coverage in advance, for up to 36 months by Aetna's COBRA Direct Billing Unit.
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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 to receive the university contribution toward the cost of health coverage for up to 12 months. If coverage is elected, you need to enroll in COBRA and will be billed for the employee portion of the cost for your health plan by Aetna's COBRA Direct Billing Unit. At the end of 12 months, if you do not have access to group health coverage, it is possible to receive up to six additional months of coverage under the COBRA coverage by paying the full employee/employer portion plus the 2% COBRA administrative fee.
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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 position 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, it is your responsibility to remove the ineligible dependent from your health insurance coverage. This will insure that your coverage is both updated and you are paying the right premium for the correct coverage level. More importantly, it will insure Aetna (the COBRA Administrator for both Aetna and HealthNow) receives information that your dependent is no longer enrolled and will send COBRA continuation of health coverage materials. Your dependent will have 60 days from the date of Aetna's Notice to enroll in COBRA coverage. The cost of COBRA coverage will be billed monthly, in advance, for up to 36 months by Aetna's COBRA Direct Billing Unit.
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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 Endowed Health Care Program can be continued 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 medical care. 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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Claims Filing
If you need assistance with filing claims, you can call Benefit Services at (607) 255-3936 and a Benefit Counselor will assist you or call Aetna's Member Services at (877) 371-2007 to check on the status of a claim.

When you are ready to submit a claim for payment, complete the first page of the claim form and then attach a copy of your itemized bill, or have your physician complete the back page of the claim form. Send it to:

Aetna
PO Box 871109
El Paso, Texas 79998-1109

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.
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