Board of Washington County Commissioners : Aetna Open Accessi

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1 aetna Accessi Aetna Select"' Low Option Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family I Plan Type: EPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall In-Network: Individual$ 0/ Family$ 0. See the chart starting on page 2 for your costs for the services this plan covers. deductible? Are there other deductibles for s You don' t have to meet deductibles for specific services, but see the chart No. services? Pe cificstarting on page 2 for other costs for services this plan covers. Is there an out- of-pocket 1 on my expenses? The out-of-pocket limit is the most you could pay during a coverage period Yes. In- Network: Individual $2, 000 / family 6, 000 usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in Premiums, balance- billed charges, and health Even though you pay these expenses, they don't count toward the out-of the out-of-pocket limit? care this plan does not cover. pocket limit. Is there an overall annual limit on what the plan pays? No The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Do I need a ref?rtal to see a specialist. Yes. See or call If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or for a list of in- network hospital may use an out-of-network provider for some services. Plans use the providers. term in- network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. No. You can see the specialist you choose without permission from this plan. Are there services this plan doesn' t cover? Yes. Some of the services this plan doesn't cover are listed on page 4. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1o 8 at or call to request a copy.

2 aetna Access'. Aetna Selector - Low Option Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family I Plan Type: EPO Copayments are fixed dollar amounts ( for example,$ 15) you pay for covered health care, usually when you receive the service. Ada Coinsurance is.your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan' s allowed amount for an overnight hospital stay is$ 1, 000, your coinsurance payment of 20% would be$ 200. This may change if you haven' t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out- of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges$ 1, 500 for an overnight stay and the allowed amount is$ 1, 000, you may have to pay the$ 500 difference. ( This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments, and coinsurance amounts. Your Cost If Your Cost If Common You Use an You Use an Medical Event Services You May Need In-Network Provider Out of Network Limitations& Exceptions Provider Primary care visit to treat an injury or $ 20 copay/ illness Includes Internist, General Physician, Family Practitioner or Pediatrician. If you visit a health Specialist visit 25 co a / none care provider' s office or clinic Other practitioner office visit 20 copay/ Preventive care/ screening immunization No charge Not covered Coverage is limited to 24 visits per calendar year for Chiropractic care. Age and frequency schedules may apply. If you have a test Diagnostic test( x-ra, blood work) No char. e Not covered none Imaging( CT/ PET scans, MRIs) No charge Not covered none- Questions: Call or visit us at com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary i. at or call to request a copy.

3 aetnae Board of Washington County Commissioners : Aetna Open Accessi' Aetna Selects" - Low Option Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family! Plan Type: EPO Your Cost If Your Cost If Common You Use an You Use an Medical Event Services You May Need In- Network Provider Out of Network Limitations & Exceptions Provider If you need drugs to Generic drugs Not covered Not covered Not covered. treat your illness or condition Prescription drug coverage is administered by ESI Preferred brand drugs Not covered Not covered Not covered. Non- preferred brand drugs Not covered Not covered Not covered. Not covered. More information about prescription drug coverage is available at Specialty drugs Not covered Not covered phar macy- insurance/ individ uals- families If you have outpatient surgery Facility fee ( e. g., ambulatory surgery center) No charge Not covered Physician/ surgeon fees No charge Not covered none If you need Emergency room services 100 copay/ visit 100 copay/ visit No coverage for non-emergency use. immediate medical attention Emergency medical transportation No charge No charge No coverage for non-emergency transport. Urgent care 35 copay/ No coverage for non-urgent use. If you have a hospital Facility fee( e. g., hospital room) 100 copay/ stay Not covered none stay Physician/ surgeon fee No charge Not covered none none If you have mental health, behavioral health, or substance Mental/ Behavioral health outpatient services Mental/ Behavioral health inpatient services 25 copay/ 100 copay/ stay Not covered none none abuse needs Substance use disorder outpatient none 25 copay/ services Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary of 8 at or call to request a copy.

4 aetna.. Access Aetna Select - Low Option Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family I Plan Type: EPO Your Cost If Your Cost If Common You Use an You Use an Medical Event Services You May Need In-Network Provider Out of Network Limitations& Exceptions Provider Substance use disorder inpatient services 100 copay/ stay Not covered none If you are pregnant If you need help or recovering have other special health needs Prenatal and postnatal care No charge Not covered none Delivery and all inpatient services 100 copay/ stay Not covered Includes outpatient postnatal care. Home health care No charge Not covered Coverage is limited to 40 visits per calendar Coverage is limited to 60 visits per calendar Rehabilitation services 20 copay/ year for Physical, Occupational& Speech Therapy combined. Habilitation services 20 copay/ year. Coverage is limited to 60 visits per calendar year for Autism Physical, Occupational& Speech Therapy, combined with rehabilitation services. Skilled nursing care No charge Not covered none Durable medical equipment No charge Not covered none Hospice service No charge Not covered none If your child needs dental or eye care Eye exam Not covered Not covered Not covered. Glasses Not covered Not covered Not covered. Dental checkup Not covered Not covered Not covered. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover ( This isn' t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Glasses( Child) Prescription drugs Bariatric surgery term care Long- Routine eye care( Adult& Child) Cosmetic surgery Non- emergency care when outside traveling the Routine foot care Dental care (Adult& Child) U.S. Weight loss programs Questions: Call or visit us at If you aren' t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 4 of 8 at or call to request a copy.

5 a tnax, Accessk Aetna Selects" - Low Option Plan, Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: EPO Other Covered Services ( This isn' t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Chiropractic care- Coverage is limited to 24 visits Infertility treatment- Coverage is limited to the Private-duty nursing- Coverage is limited to 70-8 per calendar year. diagnosis and treatment of medical underlying hour shifts per calendar year. condition. Artificial insemination, ovulation Hearing aids- Coverage is limited to 1 pair of induction& advanced reproductive technology hearing aids per 36 months up to age 19 and 1 pair limited to$ 100,000 per lifetime, and in-vitro of hearing aids per 5 years thereafter. fertilization limited to 3 attempts per lifetime. Your Rights to Continue Coverage: Ifyou lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or ebsa, or the U.S. Department of Health and Human Services at x61565 or gov. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact us by calling the toll free number on your Medical ID Card. If your group health plan is subject to ERISA, you may also contact the Department of Labor' s Employee Benefits Security Administration at EBSA( 3272) or ebsa/ healthreform. Additionally, a consumer assistance program can help you file your appeal. Contact information is at www. aetna.com/ individuals- families- health-insurance/ rights- resources/ complaints- grievances- appeals/ index.html Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as" minimum essential coverage". This plan or policy does provide minimum essential coverage. Does this Coverage Meet Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60%( actuarial value). This health coverage does not meet the minimum value standard for the benefits it provides. Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. t 8

6 y aetna Access( k Aetna Selectsm - Low Option Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: EPO Language Access Services: Para obtener asistencia en Espanol, llame al tmarn r3z titpggj, ingtm. ii Kung kailangan ninyo ang tulong sa Tagalog tumawag 7i)see examples ofhow this plan might cover costs.* sa Dinek'ehgo shika at'ohwol ninisingo, kwiijigo home' a sample medical situation, see the next p rge. Questions: Call or visit us at com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 6 of 8 at or call to request a copy.

7 aetna! Access" Aetna Select"' - Low Option Plan Coverage Examples Coverage for: Individual + Family Plan Type: EPO About these Coverage Examples: Having a baby normal delivery) Managing type 2 diabetes routine maintenance of a well- controlled condition) These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Amount owed to providers: $7, 540 Amount owed to providers: $5, 400 Plan pays: $ 7, 240 Plan pays: $ 2, 300 Patient pays: $ 300 Patient pays: $ 3, 100 Sample care costs: Sample care costs: iiii Hospital charges( mother) 2,700 Prescriptions 2, 900 This is not Routine obstetric care 2,100 Medical E ui. ment and Su.* lies 1, 300 a cost estimator. Hospital charges( baby) 900 Office Visits and Procedures 700 Anesthesia 900 Education 300 Laboratory tests 500 Laboratory tests 100 Don't use these examples to Prescriptions 200 Vaccines other. reventive 100 estimate your actual costs Radiology 200 Total 5,400 under this plan. The actual Vaccines, other preventive care you receive will be Total 7, 540 S4n Patient pays: different from these Deductibles 0 Patient pays: examples, and the cost of Copays _ 200 Deductibles Si I Coinsurance 0 1 different. Copays SI( R) Limits or exclusions 2, 900 that care also will be See the next page for important information about these examples. Coinsurance 0 Total 3, 100 Limits or exclusions S200 Total 300 Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 7 of 8 at or call to request a copy.

8 aetna Access Aetna SelectsM - Low Option Plan Coverage Examples Coverage for: Individual + Family Plan Type: EPO Questions and answers about the Coverage Examples: What are some of the assumptions What does a Coverage Can I use Coverage Examples to behind the Coverage Examples? Example show? compare plans? Yes. When you look at the Summary of For each treatment situation, the Coverage Example helps you see how deductibles, Benefits and Coverage for other plans, Costs don't include premiums. copayments, and coinsurance can add up. It you'll find the same Coverage Examples. Sample care costs are based on national also helps you see what expenses might be left When you compare plans, check the" Patient averages supplied by the U.S. Department up to you to pay because the service or Pays" box in each example. The smaller that of Health and Human Services, and aren't treatment isn' t covered or payment is limited. number, the more coverage the plan specific to a particular geographic area or health plan. The patient's condition was not an Does the Coverage Example provides. predict my own care needs? Are there other costs I should excluded or preexisting condition. All services and treatments started and No. Treatments shown are just examples. consider When comparing plans? ended in the same coverage period. There are no other medical expenses for doctor's any member covered under this plan. The care you would receive for this condition could be different, based on your advice, your age, how serious your Yes. An important cost is the premium condition is, and other many factors. you pay. Generally, the lower your Out-of-pocket expenses are based only onpremium,the more you'll pay in treating the condition in the example. out-of-pocket The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. Does the Coverage Example predict my future expenses? also No. Coverage Examples are not cost estimators. You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. costs, such as copayments, deductibles, and coinsurance. You should consider contributions to accounts such as health savings accounts( HSAs), flexible spending arrangements( PSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 8 of 8 at or call to request a copy.