Fill and Sign the Power of Attorney Form Giving Custody of Child

Pennsylvania DU30 Supplemental Enrollment Form Implementing P.L. 682, No. 284 Aetna Health Inc./Aetna Health Insurance Company/Aetna Life Insurance Company A. Group & Employee Information Group Name Group Number/Control Number Employee Name Aetna Member ID Number B. Type of Activity (see Important Explanatory Information below) Change - Check all that apply Effective Date / / / / Add dependent over the limiting age, but less than 30 Remove dependent over the limiting age, but less than 30 Reason(s): Continuation of Coverage pursuant to P.L. 682, No. 284 Effective Date Coverage is being elected: / / During an Open Enrollment Within 30 days after eligibility for other reasons Within 30 days prior to or following the attainment of limiting age Billing: (Aetna will bill over-age dependents directly and enrollees will remit the premium directly to Aetna.) X Direct bill dependent (add billing address, required even if the same as the employee’s address): Street, Apt. Number: City, State, ZIP Code: C. Over-age Dependent Information Name (Last, First, MI) Sex Birthdate (MM/DD/YYYY) M Yes Other Health Coverage: Primary Physician Office ID Number: Current Patient: Yes Previous Coverage: Yes F / Social Security Number / No Other Rx Drug Coverage: Yes No No Ob/Gyn Physician Office ID Number: Current Patient: Yes No No Effective date of prior coverage: Name of prior carrier: N/A If yes, provide the following information AND submit a copy of the certificate of Creditable Coverage that was issued by the previous carrier, if available: / / / / Termination date of prior coverage: Prior plan number: D. Signature I have read the Important Information below and agree to the conditions of enrollment. The information supplied in this application is true and complete. Employee Signature Employer Signature Date Dependent Signature Date Title Date Important Information Regarding Cost-Sharing Limitations The employee must continue coverage in order for the dependent to be covered in addition to the additional applicable eligibility criteria. Coverage for the dependent will be issued as stand-alone coverage. All cost-sharing requirements and limitations will apply and will not be combined with the employee’s policy. Consequently, covered expenses incurred by the over-age dependent will not contribute to family deductibles and out-of-pocket maximums, nor will family incurred expenses contribute to the over-age dependent’s deductibles or out-ofpocket maximums. IMPORTANT EXPLANATORY INFORMATION An adult child may request to continue as a dependent on his or her parent’s coverage even after the child reaches the limiting age under the terms of the policy if the adult child: • is not yet 30 years old; • is unmarried; • has no children; • lives in Pennsylvania or, if not a Pennsylvania resident, is a full-time student at an accredited institution of higher education; and • is not eligible for Medicare and is not actually covered under another group or individual health plan. An adult child may make written request to continue as a dependent on his or her parent’s coverage either: • within 30 days prior to or following the termination of coverage at the specific age provided in the contract’s language; • within 30 days after meeting the requirements for dependent status, when coverage for the dependent had previously terminated; • during the open enrollment period for the group of which the parent is a member, when the dependent meets the requirements for dependent status during the open enrollment period. (Dependent child will be enrolled in same coverage as that of the parent(s).) The adult child or covered employee will be required to pay 150 percent of the cost of the employee premium. GR-68189-5 (10-09) PA R-POD