DS9 Document EFTA00316503

aetna Mina Mn: Billing Shaman/ Disl P.O.BOX 67103 Harrisburg PA 17106-7103 4:0652WIPUSWOMMIIII15542ACCO) *******************ALL FOR AADC 100 7201 2 AB 0.412 NES, tic GO HBRK ASSOCIATES 575 LEXINGTON AVE 4vm FL NEW YORK NY 10022-6146 30 Pg. 1 of 7 Prepared Date: 05/15/19 Invoice Number: Triad Number: Account Number: Bill Package: 1001 Coverage Period: 06/01/19-06/30/19 Payment Due Date: 06/01/19 SUMMARY OF ACCOUNT: Opening Balance $(12,248.40) Total Payments Received Since Last Invoice $0.00 Current Inforce Charges Retroactivity Charges Current Admin/Other Adjustment Charges Current Net Charges 61,818.80 $0.00 $0.00 $1,818.80 AMOUNT DUE: $(10,429.60) Total amount due includes the premium due to your health plan, as well as any service fee you are paying your broker as outlined in the executed billing and collection agreement. Please refer to your copy of the billing and collection agreement for details. If you have any questions, please contact your Account Manager. Important Please Read: The total amount is due on the 1st day of the monthly coverage period. In the coverage period, you have a grace period to pay. If the total amount is not received by the end of the grace period, the contract will be terminated. You will be liable for the total amount due for all periods of coverage (including the grace period) unless you provide at least 30 days of advance written notice of your intent to terminate. If you have more than one invoice, you must pay each invoice separately or supply support detailing the amount to apply to each invoice. If you fail to supply this support your payment will be applied proportionately to each invoice for that month. If the total amount due for all invoices is not received, you may be in arrears on all invoices, and subject to termination. Aetna and Aetna Business plans administered by Aetna will appear as ALIC or AHM on your financial institution statement Pay online htto://www.aetna.corntemolover-olans/index.html, or call 866-350-7644. Go paperless with eBilling - view, print and pay your invoice online. Just call 800-297-7145 for billing questions. Please include your invoice number and/or account number on your check. Thank you for your Business. Detach & return with payment in the enclosed envelope. aetna Please make checks payable to: AETNA P O BOX 775392 CHICAGO, IL 8%77 -5392 Prepared Date: 05/15/19 Invoice Number: Triad Number. Account Number: Bill Package: 1001 Coverage Period: 06/01/19-06/30/ I 9 Please Pay By Amount Due June 01,2019 5(10,429.60) K Check Box for Change of Address. See Reverse. 01 E10B 0000000081115562 1001 00001042%0 5 EFTA00316503 .O1.15Ja J[LIFUJIi V!0(Wai liC.,02.11/41 II; Pg. 2 of 7 *Plan Key Please reference this key while reviewing membership at benefit level. Product Specific Plan Type Dental PPO *Type Dental 0100 Family Code Description 1 EE 2 EE + Spouse 3 EE + Family Please insert Change of Address information in the space provided Name Addr 1 Addr 2 City, State, Zip EFTA00316504 Obtrid Mai/di I 10O1,Z• WU I I II O N aetna NES, LLC Pg. 3 of 7 Prepared Date: 05/15/19 Invoice Number: Triad Number: Account Number: Bill Package: 1001 Coverage Period: 06/01/19-06/30/19 Empl Name Empl ID I Family Code I Dental Total 'Type Amount Dela cruz. Merv* t0002411 3 0100 230.20 $230.20 I Indyke, Darren toixxx8.596 3 0100 230.20 5230.20 Kahn, Richard iavo:9833 3 0100 230.20 $230.20 Klein, Bella ruxx4538 3 0100 230.20 $230.20 Rawson, Peter khczxx7217 1 0100 76.60 576.60 Rodgers, David tocax5547 2 0100 142.20 $142.20 Rothel, Darren nocrx4615 3 0100 230.20 5230.20 Toykk Carluz mor1400 2 0100 142.20 $142.20 Visoski, Larry r000c5821 3 0100 230.20 $230.20 Total Due for above Coverages $1,818.80 51,818.80 'Soo Plan Kay EFTA00316505 aetnas NES, LLC RETROACTIVITY CHARGES/CREDITS No Retroactivity Pg. 4 of 7 Prepared Date: 05/15/19 Invoice Number: Triad Number: Account Number: Bill Package: 1001 Coverage Period: 06/01/19.06/30/19 Current Admin/Other Adjustments Date Amount Remarks Total Admin/Other Adjustments $0.00 EFTA00316506 11871188 D i 2019051080S J2 20143518 5322 ErnP.20113d. 8 1 Pg. 5 of 7 aetna NES, LLC BENEFIT SNAPSHOT CURRENT MEMBERSHIP Recorded Empl / Volume Product 'Plan Type Description Empl / Volume Amount Dental 100 EE 2 S153.20 EE + Spouse 2 $284.40 EE + Family 6 $1,381.20 Subtotal $1,818.80 Total $1,818.80 'See Plan Key Prepared Date: 05/15/19 Invoice Number: Triad Number: Account Number: Bill Package: 1001 Coverage Period: 06/01/19-06/30/19 ACTIVE CONTROL-SUFFIX-ACCOUNTS (CSA) REFLECTED IN THIS INVOICE 0797468-031-00000 FIX63220C0004030003100J287USR99Cf EFTA00316507 Pg. 6 of 7 Your rights and obligations when your Aetna group plan terminates In the event of policy termination, New York Law requires we tell you of your obligation to comply with NY Labor Law section 217 and NY Insurance Regulation 78. Under this law and regulation you must notify, in writing, each certificate holder (covered employee) resident in New York State who is insured under your group policy that the policy will end. If Aetna should terminate your plan, you must take the following steps prior to your policy's intended termination date: " Provide the enclosed notice, along with a cover letter saying when the plan will end, to each certificate holder at least nine (9) days before the intended termination date. The notice must be: 1) Hand-delivered at the certificate holder's workplace (e.g., you may include the notice in the employee's pay envelope). OR 2) Mailed to the certificate holder's last known home address. Also, at least 9 days before the intended termination date, you must post a copy of any notice of intent to terminate your plan that you may receive from Aetna in a spot where employees are most likely to see it. Note that in accordance with the provisions of Labor Law, section 217(4), the above provisions and the notice requirement of Labor Law, section 271(3), shall not apply if, at least 10 days prior to the intended termination date, you: (1) Take any necessary steps to keep the policy in force. (2) Contract with another insurer to replace Aetna to provide similar coverage for the same certificate holders. You must file an affidavit with the Commissioner of Labor and Superintendent of Insurance to that effect. (i) Affidavits filed with the Commissioner of Labor shall refer to Labor Law, section 217, and be addressed to: Director of Labor Standards Department of Labor Agency Building 12 State Office Building Campus Albany. NY 12240 (ii) Affidavits filed with the Superintendent of Insurance shall refer to Labor Law, section 217, and shall be addressed to: Chief, Health Bureau New York State Insurance Department One Commerce Plaza Albany, NY 12257 For more information if you need assistance or have any questions about these requirements, please contact us at the telephone number on your billing statement. As required by the New York Labor Law section 217 and New York Insurance Regulation 78. the enclosed member rights document is to be delivered toemplovees and posted at your place of employment whenever notice is received from Aetna indicating intent to terminate your group policy. EFTA00316508 '005322%1297USA*0182221)i I I M62. POO Pg. 7 of 7 Important Information for Aetna New York Group Health Plan Certificate Holders This notice is to advise you and your dependents of the rights/benefits available under your group health plan should Aetna terminate the group health policy with your employer. Please review the available coverage descriptions below. Also note that you and your dependents will be responsible for all charges associated with services received after the termination date. Extension of Benefits While Member is Receiving Inpatient Care - For Aetna HMO Plan members If you are receiving inpatient care in a Hospital or Skilled Nursing Facility on the date when group coverage terminates. you may be covered only for the specific medical condition causing that confinement or for complications arising from the condition causing that confinement, until the earlier of: 1. The date of discharge from such inpatient stay; 2. Determination by the HMO Medical Director in consultation with the attending Physician, that care in the Hospital or Skilled Nursing Facility is no longer Medically Necessary; 3. The date the contractual benefit limit has been reached; 4. The date the Member becomes covered for similar coverage from another health benefits plan; or 5. 12 months of coverage under this extension of benefits provision. The extension of benefits shall not extend the time periods during which you may enroll for conversion coverage, expand the benefits for such coverage, nor waive the requirements concerning the payment of premium for such coverage. 'tension of Benefits - Total Disability - For Aetna HMO and PPO Plan members • ; at may be able to extend your health benefits if you are totally disabled when coverage under your certificate ; urinates, but with respect medical benefits, only as to the expenses incurred in connection with the injury or illness § • e it caused the total disability for up to 12 months from the date that your certificate terminates. otally disabled" means that because of an injury or illness: • You are not able to work at your own occupation and you cannot work at any occupation for pay or profit. • Your dependent is not able to engage in most normal activities of a healthy person of the same age and gender. tension of your benefits (other than Basic benefits) will end on the first to occur of: • The date that is 12 months from the date that your certificate terminates, or • The date that you or your dependent are no longer totally disabled, or • The date any applicable benefit maximum or your Lifetime Maximum Benefit, if any, is reached. Conversion from a Group to an Individual Plan - For Aetna HMO and PPO Plan members If loss of coverage under your group health plan occurs and is not replaced with continuous or similar coverage by the Contract Holder, you may within 45 days after termination of coverage apply for an individual health plan (to be effective as of the date of such termination) without providing proof of good health. The conversion coverage will provide no less that what is then required by, and not benefits to the contrary to, any applicable law or regulation. However. the individual policy will not provide the same coverage as the former croup plan offered by your emolover.Certain benefits may not be available. You will be required to pay the associated premium costs for the coverage. Further details about extension of benefits or conversion are contained in your group member certificate under the section Termination of Coverage. For additional information, contact your employer or call the toll-free number on your member ID card. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, Including Aetna Lite insurance Company and Its affiliates (Aetna). 1432.132,1-tr, EFTA00316509 10600644 040f 116.101 V IOW 064 um 600,1 IFI EFTA00316510