BENEFITS SUMMARY. Aetna Hospital Plan

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Irma Cross
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1 Helthier living Finncil well-being THIS IS NOT A MEDICARE SUPPLEMENT PLAN. If you re eligible for Medicre, review the free Guide to Helth Insurnce for People with Medicre vilble from the compny or t Hospitl Pln Lump-sum benefit BENEFITS SUMMARY Aetn Hospitl Pln Insurnce plns re underwritten by Aetn Life Insurnce Compny. Unless otherwise indicted, ll benefits nd limittions re per covered person. IMPORTANT INFORMATION ABOUT THE BENEFITS YOU ARE BEING OFFERED: The Aetn Hospitl Pln is hospitl confinement indemnity pln. This pln provides LIMITED BENEFITS. This pln pys you fixed dollr mounts regrdless of the mount tht the provider chrges. You re responsible for mking sure the provider's bills get pid. These benefits re pid in ddition to ny other helth coverge you my hve. This disclosure provides very brief description of the importnt fetures of the benefits being considered. It is not n insurnce contrct nd only the ctul policy provisions will control. THIS PLAN DOES NOT COUNT AS MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. $1,000 for the first dy of one covered inptient hospitl sty per coverge yer; plus Dily benefit $100 per dy for covered inptient hospitl stys Up to 100 dys per coverge yer This provides benefits if you or covered dependent re dmitted to the hospitl s n inptient. Benefits re provided for Inptient Hospitl Stys ("Stys") only. A Sty is period during which you re dmitted s n inptient; nd re confined in hospitl, non-hospitl residentil fcility, hospice fcility, skilled nursing fcility, or rehbilittion fcility; nd re chrged for room, bord, nd generl nursing services. A Sty does not include time in the hospitl becuse of custodil or personl needs tht do not require medicl skills or trining. A Sty specificlly excludes time in the emergency room unless this leds to Sty. This policy does not meet Msschusetts Minimum Creditble Coverge stndrds. 10/21/2016 Benefits Summry Pge 1

2 Helthier living Finncil well-being Hospitl Pln Limittions nd Exclusions: This pln hs exclusions nd limittions. Refer to the ctul policy nd booklet certificte to determine which helth cre services re covered nd to wht extent. The following is prtil list of services nd supplies tht re generlly not covered. However, the pln my contin exceptions to this list bsed on stte mndtes or the pln design purchsed. All medicl or hospitl services not specificlly covered in, or which re limited or excluded in the pln documents. Cosmetic surgery, including brest reduction. Custodil cre. Experimentl nd investigtionl procedures. Infertility services, including donor egg retrievl, rtificil insemintion nd dvnced reproductive technologies. Reversl of steriliztion. Nonmediclly necessry services or supplies. Over-the-counter medictions nd supplies. No benefit is pid for or in connection with the following stys or visits or services: Those received outside the United Sttes Those for eduction, specil eduction or job trining, whether or not given in fcility tht lso provides medicl or psychitric tretment. Emergency room (unless emergency room leds to n Inptient Sty). Questions nd nswers Wht should I do in cse of n emergency? In cse of emergency, cll 911 or your locl emergency hotline, or go directly to n emergency cre fcility. Wht if I don t understnd something I ve red here, or hve more questions? Plese cll us. We wnt you to understnd these benefits before you decide to enroll. You my rech one of our Customer Service representtives Mondy through Fridy, 8.m. to 6 p.m., by clling toll free We re here to nswer questions before nd fter you enroll. 10/21/2016 Benefits Summry Pge 2

3 Helthier living Finncil well-being Importnt informtion bout your benefits Complints nd ppels Plese tell us if you re not stisfied with response you received from us or with how we do business. Cll Member Services to file verbl complint or to sk for the ddress to mil written complint. You cn lso e-mil Member Services through the secure member website. If you re not stisfied fter tlking to Member Services representtive, you cn sk us to send your issue to the pproprite deprtment. If you don t gree with denied clim, you cn file n ppel. To file n ppel, follow the directions in the letter or explntion of benefits sttement tht explins tht your clim ws denied. The letter lso tells you wht we need from you nd how soon we will respond. We protect your privcy We consider personl informtion to be privte. Our policies protect your personl informtion from unlwful use. By personl informtion, we men informtion tht cn identify you s person, s well s your finncil nd helth informtion. Personl informtion does not include wht is vilble to the public. For exmple, nyone cn ccess informtion bout wht the pln covers. It lso does not include reports tht do not identify you. When necessry for your cre or tretment, the opertion of our helth plns or other relted ctivities, we use personl informtion within our compny, shre it with our ffilites nd my disclose it to: your doctors, dentists, phrmcies, hospitls nd other cregivers, other insurers, vendors, government deprtments nd third-prty dministrtors (TPAs). We obtin informtion from mny different sources prticulrly you, your employer or benefits pln sponsor if pplicble, other insurers, helth mintennce orgniztions or TPAs, nd helth cre providers. These prties re required to keep your informtion privte s required by lw. Some of the wys in which we my use your informtion include: Pying clims, mking decisions bout wht the pln covers, coordintion of pyments with other insurers, qulity ssessment, ctivities to improve our plns nd udits. We consider these ctivities key for the opertion of our plns. When llowed by lw, we use nd disclose your personl informtion in the wys explined bove without your permission. Our privcy notice includes complete explntion of the wys we use nd disclose your informtion. It lso explins when we need your permission to use or disclose your informtion. We re required to give you ccess to your informtion. If you think there is something wrong or missing in your personl informtion, you cn sk tht it be chnged. We must complete your request within resonble mount of time. If we don t gree with the chnge, you cn file n ppel. If you d like copy of our privcy notice, cll or visit us t If you require lnguge ssistnce, plese cll Member Services t nd n Aetn representtive will connect you with n interpreter. If you re def or hrd of hering, use your TTY nd dil 711 for the Telecommunictions Rely Service. Once connected, plese enter or provide the Aetn telephone number you re clling. Si usted necesit sistenci lingüístic, por fvor llme l Servicios l Miembro , y un representnte de Aetn le conectrá con un intérprete. Si usted es sordo o tiene problems de udición, use su TTY y mrcr 711 pr el Servicio de Retrnsmisión de Telecomunicciones (TRS). Un vez conectdo, por fvor entrr o proporcionr el número de teléfono de Aetn que está llmndo. 10/21/2016 Benefits Summry Pge 3

4 Helthier living Finncil well-being ATTENTION MASSACHUSETTS RESIDENTS: As of Jnury 1, 2009, the Msschusetts Helth Cre Reform Lw requires tht Msschusetts residents, eighteen (18) yers of ge nd older, must hve helth coverge tht meets the Minimum Creditble Coverge stndrds set by the Commonwelth Helth Insurnce Connector, unless wived from the helth insurnce requirement bsed on ffordbility or individul hrdship. For more informtion cll the Connector t MA- ENROLL ( ) or visit the Connector website ( THIS POLICY, ALONE, DOES NOT MEET MINIMUM CREDITABLE COVERAGE STANDARDS. If you hve questions bout this notice, you my contct the Division of Insurnce by clling or visiting its website t ATTENTION MISSOURI RESIDENTS: An optionl rider for elective bortion hs not been purchsed by the group contrct holder pursunt to VAMS section An enrollee who is member of group helth pln with coverge for elective bortions hs the right to exclude nd not py for coverge for elective bortions if such coverge is contrry to his or her morl, ethicl or religious beliefs. Your pln sponsor does not include coverge for elective bortions. This mteril is for informtion only nd is not n offer or invittion to contrct. Insurnce plns contin exclusions nd limittions. Supplementl helth plns provide limited benefits. The benefit pyments re not intended to cover the full cost of medicl cre. Providers re independent contrctors nd re not gents of Aetn. Provider prticiption my chnge without notice. Aetn does not provide cre or gurntee ccess to helth services. Not ll helth services re covered. See pln documents for complete description of benefits, exclusions, limittions nd conditions of coverge. Pln fetures nd vilbility my vry by loction. Informtion is believed to be ccurte s of the production dte; however, it is subject to chnge. For more informtion bout Aetn plns, refer to Finncil Snctions Exclusions Cluse If coverge provided by this policy violtes or will violte ny US economic or trde snctions, the coverge is immeditely considered invlid. For exmple, Aetn compnies cnnot mke pyments or reimburse for helth cre or other clims or services if it violtes finncil snction regultion. This includes snctions relted to blocked person or entity, or country under snction by the United Sttes, unless permitted under vlid written Office of Foreign Assets Control (OFAC) license. For more informtion on OFAC, visit Policy forms issued in Oklhom nd Idho include: GR-96172, GR /21/2016 Benefits Summry Pge 4

5 Non-Discrimintion Notice Aetn complies with pplicble Federl civil rights lws nd does not discriminte, exclude or tret people differently bsed on their rce, color, ntionl origin, sex, ge, or disbility. Aetn provides free ids/services to people with disbilities nd to people who need lnguge ssistnce. If you need qulified interpreter, written informtion in other formts, trnsltion or other services, cll If you believe we hve filed to provide these services or otherwise discriminted bsed on protected clss noted bove, you cn lso file grievnce with the Civil Rights Coordintor by contcting: Civil Rights Coordintor, P.O. Box 14462, Lexington, KY (CA HMO customers: PO Box Fresno, CA 93779), , TTY: 711, Fx: (CA HMO customers: ), You cn lso file civil rights complint with the U.S. Deprtment of Helth nd Humn Services, Office for Civil Rights Complint Portl, vilble t or t: U.S. Deprtment of Helth nd Humn Services, 200 Independence Avenue SW., Room 509F, HHH Building, Wshington, DC 20201, or t , (TDD). Aetn is the brnd nme used for products nd services provided by one or more of the Aetn group of subsidiry compnies, including Aetn Life Insurnce Compny, Coventry Helth Cre plns nd their ffilites (Aetn) (10/16)

6 Avilbility of Lnguge Assistnce Services TTY: 711 For lnguge ssistnce in your lnguge cll t no cost. (English) Pr obtener sistenci lingüístic en espñol, llme sin crgo l (Spnish) 欲取得繁體中文語言協助, 請撥打 , 無需付費 (Chinese) Pour une ssistnce linguistique en frnçis ppeler le sns fris. (French) Pr s tulong s wik n ns Tglog, twgn ng nng wlng byd. (Tglog) Benötigen Sie Hilfe oder Informtionen in deutscher Sprche? Rufen Sie uns kostenlos unter der Nummer n. (Germn) للمساعدة في (اللغة العربیة) الرجاء الاتصال على الرقم المجاني (Arbic) Pou jwenn sistns nn lng Kreyòl Ayisyen, rele nimewo grtis. (French Creole) Per ricevere ssistenz linguistic in itlino, può chimre grtuitmente (Itlin) 日本語で援助をご希望の方はまで無料でお電話ください (Jpnese) 한국어로언어지원을받고싶으시면무료통화번호인 번으로전화해 주십시오. (Koren) برای راھنمایی بھ زبان فارسی با شماره بدون ھیچ ھزینھ ای تماس بگیرید. انگلیسی (Persin) Aby uzyskć pomoc w języku polskim, zdzwoń bezpłtnie pod numer (Polish) Pr obter ssistênci linguístic em português ligue pr o grtuitmente. (Portuguese) Чтобы получить помощь русскоязычного переводчика, позвоните по бесплатному номеру (Russin) Để được hỗ trợ ngôn ngữ bằng (ngôn ngữ), hãy gọi miễn phí đến số (Vietnmese) (10/16)

Financial protection for out-of-pocket costs Aetna Hospital Plan

Financial protection for out-of-pocket costs Aetna Hospital Plan Finncil protection for out-of-pocket costs Aetn Hospitl Pln Csh benefits directly to you if you re hospitlized Would you be ble to py some of your dy-to-dy living expenses if you were hospitlized? Now