SACM Student Guide. Answers to your ques ons about your Aetna Interna onal plan. Mission Statement: Onsite SACM Team, Fairfax, VA

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1 SACM Student Guide Answers to your ques ons about your Aetna Interna onal plan Mission Statement: Onsite SACM Team, Fairfax, VA As an ambassador to health care in the U.S., Aetna Interna onal's Onsite Service and Support Team s func on is to serve as a SACM student health care "advocate". We promote an environment of friendship and stewardship as you adjust to your new environment in the U.S. In a spirit of true partnership and collabora on with SACM, Aetna network providers and U.S. learning ins tu ons, we provide access to health care while promo ng health educa on for healthy living. This enhances the student scholarship experience in support of the SACM mission. ()

2 The Aetna Way Our Core Values Empowering people to live healthier lives through innova ve global coverage, wellness and care management solu ons. s (2)

3 We Focus on Your Health You Focus on Your Study Table of Contents Health Insurance General Information 3 Student Medical Plan Benefits 5 Applying for your Health Insurance ID Card 8 How to Find a Health Care Provider 10 Why Find a Primary Care Doctor 10 How to Access Emergency & Urgent Care 11 How to File a Claim 12 Useful Questions & Answers 13 How to Contact Us 16 Your health and wellness play an important role in your everyday life. We know how important it is to receive quality and mely medical care, no ma er when or where you need it. That s where we come in. Aetna Interna onal is here to make sure you have access to the care that you need in the event of a rou ne or emergency medical situa on. Our service model places you at the center of everything we do, ensuring that you receive the care you need with ul mate convenience. With Aetna Interna onal as your health benefits provider, you can rest assured that you will have reliable services and world-class resources. For over 30 years, we have been working to make it as easy as possible for our members to access quality health care, wherever they go. Now, it s me for you to experience the Aetna Interna onal difference. Within this guide, you will find valuable informa on on the programs and services available to you as an Aetna Interna onal member. We encourage you to read these materials to learn about your plan and how to use your benefits. (3)

4 Why Health Insurance Both the private and public sectors provide very high quality medical care in the United States. However, it is important for visitors and students to the United States to have health insurance to cover the costs of medical care. Costs for doctor and hospital care can be very high without insurance. Insurance policies differ in terms of the covered services, available doctors and hospitals, deductibles to meet, and copayments the patient may have to make. Insured people should make every effort to understand the terms and conditions of their insurance policy. Your Medical Coverage PPO Plan: Aetna provides a generous health insurance benefits plan for SACM students inside and outside the U.S. SACM students are covered at 100% for medically necessary care and services. The Aetna network is one of America s largest health care networks, with over 1 million U.S. network providers. Please note when using providers not in the network (in the US) you will be responsible for a $100 copayment to be paid at the time services are rendered for each visit. Your medical plan includes: 100% coverage anywhere in the world Doctor office visits (primary care physicians and specialists) Diagnostic lab and radiology tests Vision care Dental care, including orthodontia coverage for dependent children Pharmacy coverage Inpatient and outpatient care Preventive care (routine physicals, immunizations, cancer screenings) Inpatient and outpatient mental health services Home health care Maternity care Spinal disorder treatment Short-term rehabilitation (physical, occupational and speech therapy) Emergency and urgent care For the summary of your medical plan coverage, refer to the next pages or call the Aetna Interna onal Member Service Center at (4)

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9 How to Apply for your Health Insurance ID Card To view instructions for the following resources supported through the aetnainternational.com website, select the link below (or copy/paste it into your browser): - Aetna International Member Website Registration - Photo Upload for Photo ID Cards; and - Navigator Profile Creation to view your claim Explanations of Benefits (9)

10 How to Find a Health Care Provider Visit our DocFind online directory at 1. Insert Name of the doctor, specialty, procedure or health condi on. 2. Insert your Zip Code, or city and State. 3. Under Plan for medical, choose Open Choice PPO, If you are looking for DENTAL, your plan will be: PPO/PDN 4. Select con nue to get the names and addresses of the health providers. You can narrow the search by specifying: Distance, language, etc Primary Care Physician (PCP) Primary care doctors will guide your way Visi ng a PCP (for example, internist, pediatricians, general prac oners) Your PCP is the doctor you go to first. He or she will help you learn about your health and how to manage it. Go to your PCP for checkups, or whenever you are sick or hurt. Your PCP will help you decide if you need care from another doctor. Appointments are typically required at doctor s offices and may not always be available on the same day you call. Choosing a PCP You can choose any PCP from Aetna s network. Plus, it s good to know that anyone you choose meets our standards. Choosing a doctor is a personal decision that s why each member of your family can have his or her own PCP. You can change your PCP at any me. A primary care physician (PCP) will get to know you and help you get the care you need. We encourage you to visit a PCP, who can be your main point of contact for your health care needs. (10)

11 Emergency and Urgent Care Tips on Emergency Room Use More convenient op ons to consider The average Emergency Room (ER) visit tops three hours, while urgent care visits are generally an hour or less¹. To receive faster, more convenient treatment, you can visit an urgent care center or walk-in clinic for non-life threatening medical issues. However, you should go straight to the nearest ER when you experience a life-threatening problem, uncontrolled bleeding, heart a ack, stroke or unconsciousness. You are covered for emergency room care, however, all emergency room care will require a copayment, paid by you at the me of service, in the amount of $100. There is no limit to the amount of copayments you will be required to pay. Every me you seek care in an emergency room, you will be responsible for a $100 copayment. In cases of non emergency care needs, please seek care through a primary care physican s office, urgent care facili es and walk in clinics. Frequently Asked Ques ons What is the Informed Health Line? It is a toll-free number accessible 24 hours a day, 7 days a week. You can speak with a registered nurse regarding your health-related ques ons. The helpful audio health library has hundreds of topics in English. What is the number to the Informed Health Line? What is the difference between a walk in clinic and urgent care center? A walk in clinic is found in stores and pharmacies, and typically keep extended business hours. They offer convenient, low cost treatment for minor medical problems such as ear infec ons, colds, allergies, strep throat and bronchi s. An urgent care center provides care for more serious problems such as sprained ankles, fevers and minor cuts and burns. How do I locate a walk in clinic or urgent care center? You can visit the DocFind online provider directory at What is the most cost effec ve care op on? The most cost effec ve op on is typically a walk-in clinic, followed by urgent care centers. In case of a medical emergency, you should proceed directly to the nearest medical loca on for immediate care. How do I know if it is a true emergency? It is an emergency if you are experiencing a life-threatening medical condi on. (11)

12 How to File a Claim (for out of network care and care received in Saudi Arabia) 1. Complete the appropriate claim form, which can be found on your Aetna Interna onal secure member website at onal.com (Resources > Forms). 2. Copy all receipts on a single piece of paper (or as many as necessary). Be certain that all receipts are legible. Receipts must be fully itemized bills and/or detailed receipts that include diagnosis (nature of illness) and the procedures or services performed. 3. Write your member iden fica on number on each document submi ed with your claim form (refer to your ID card). 4. Be sure to indicate the name of the person who received care (either yourself or your dependent). 5. Include contact informa on (phone or fax) where you can be reached in case we have any ques ons about your claim. Comple ng your claim form While it is important to fill out your claim form in its en rety, here are some fields in par cular to pay close a en on to: A. Pa ent s Name The person who received the care/service(s). Please indicate if it is you or your eligible dependent that received the service(s). B. Dates of Service The date(s) that you or your dependent received the service(s). Please list in the following format: MM/DD/YYYY. C. Descrip on of Service The service(s) that were received (e.g., office visit, X-ray). D. Diagnosis (reason for visit) The reason for obtaining the service(s) (e.g., well-visit checkup, broken wrist, influenza). E. Summary of Reimbursement Select the appropriate checkbox to indicate your preferred method of reimbursement (e.g. electronic funds transfer, check or wire). To ensure mely claim reimbursement, please make sure to fill out the claim form completely and sign it. Any missing informa on may result in a delay in reimbursement. Then submit it to Aetna either by fax: or E mail: aiservice@aetna.com (12)

13 Useful Ques ons and Answers General Information Am I covered for medical expenses anywhere in the world? Yes. Coverage is provided to enrolled students, a ending school in the U.S., and their enrolled dependents. Does coverage terminate with Aetna Interna onal when I temporarily return to my home country for vaca on? No. Coverage stays with you anywhere in the world. Care received in the Kingdom of Saudi Arabia should be paid for up front by you and submi ed to Aetna by way of claim form. Please a ach receipts for reimbursement. What type of customer assistance does Aetna Interna onal provide to members? Aetna Interna onal customer service professionals are mul lingual representa ves with the ability to converse, comprehend and translate virtually any language including Arabic. Our highly trained representa ves are available 24 hours a day, 7 days a week at In addi on to personalized assistance, you have access to integrated, self-service Web tools through our password-protected member website. A dedicated team of Arabic speaking clinical case managers are also available to assist you with specialty care. Who should I tell about changes in family status? You should no fy SACM within 30 days of any change to your family status. Changes in family status may include: marriage, divorce, or legal separa on; birth or adop on; or death of a child or spouse. All changes must be made through the MoHE student website. Insurance Terminology A PPO, or preferred provider organiza on, is a group of U.S.-based hospitals, doctors and other health care professionals who have agreed to provide contracted health care services to Aetna Open Choice PPO plan par cipants. You are free to receive services from any health care provider you wish, but we recommend you use an Aetna PPO provider to avoid any out of pocket costs. When you use health care professionals (hospitals, doctors, den sts, labs, pharmacies) who belong to the Aetna PPO network, all of your medical claims will be paid at 100% with no addi onal costs to you. Whose responsibility is it to verify that a provider is in the PPO network? It is always the member s responsibility to verify that a provider is par cipa ng in the PPO network. These providers are known as preferred providers. You should verify this before each visit with a new provider by checking your member website or calling Aetna Interna onal Member Services. You may also do so by calling the provider s office. This includes doctors, hospitals, labs, pharmacies, etc. You are enrolled in the Aetna Open Choice PPO plan. When looking for network providers, please search for providers listed under this plan name. What are Reasonable and Customary Guidelines? What happens if my claim exceeds the Reasonable and Customary Guidelines? Reasonable and Customary (R&C) Guidelines are applied to claims incurred in the United States. They are geographicallydetermined average claim costs for various types of medical services. The guidelines are used to determine if a provider (doctor, hospital, etc.) is charging too much money for any given service more than what is reasonable and customary for a service within a defined geographic area. If your claim exceeds Reasonable and Customary Guidelines and you received care from a preferred provider, you will not be responsible for any amount over what is reasonable and customary. However, if you received care from a non-preferred provider, you would be responsible for paying for the en re amount over what is determined to be reasonable and customary. Claims from providers outside the United States are not subject to Reasonable and Customary guidelines. Please see the example below: In Network Provider (Preferred) Out of Network Provider (Non Preferred) Doctor Office Visit Doctor Files Claim Doctor Office Visit Student files claim Charge: $450 Charge: $450 R&C Amount: $300 R&C Amount: $300 Aetna Reimbursement: $300 Aetna Reimbursement: $200 Student Owes: $ 0 Student Copay: $100 Student Owes: $150 (copayment plus $$$ above R&C) (13)

14 Does this plan cover everything the doctor orders or recommends? No. This plan is very comprehensive and covers most services at 100%. However, the plan does not cover items that are experimental. The plan also covers services based on medical necessity, and there are criteria that need to be met for certain services. If you do not meet this criteria, the plan will not cover the service. Informa on on this criteria can be found at Maternity Care How is maternity care covered? As with all providers, it is your responsibility to verify if your provider is in the Aetna Open Choice PPO network. If your doctor is in the network, you are covered at 100% for all treatment related to your pregnancy. Out of network providers will require a $100 copayment for each visit at the me services are rendered. If you are required to go to a facility outside of your doctor s office for related tests, the facility must be part of the PPO network for your bill to be paid at 100%. It is your responsibility to confirm with your doctor or with the facility that it is part of the Aetna PPO network. When you go to a preferred hospital to deliver your baby, the hospital and doctor charges will be covered at 100%. If your doctor is not in the PPO network, your out-of-pocket expenses may be significantly higher. If you see a doctor outside of the PPO network, you will be required to pay any amounts over the Reasonable and Customary level. This policy is applicable to every office visit. If you deliver your baby at a non-preferred hospital, you are responsible for paying any amounts over the Reasonable and Customary level. Regardless of network par cipa on, personal items are not covered under this plan. This would include items such as, but not limited to, television, telephone or guest food trays. What type of doctor should I see if I am pregnant? There are several types of doctors who can treat you for your prenatal care, such as an obstetrician and/or gynecologist. Obstetricians and gynecologists are specifically trained in this field, and can deliver babies either vaginally or by cesarean sec on. However, it is up to you to select the type of doctor that is right for you. How do I enroll my newborn baby? Once the baby is born, we will pay the newborn claims for the first 30 days of the baby's life as part of the member s or covered dependent s exis ng plan of benefits. Within the first 30 days of the baby s birth, you must contact SACM to enroll the baby in your plan. If your baby is not enrolled within the first 30 days of birth, he/she will not be covered for health care expenses under your plan of benefits. Please contact SACM within the first 30 days of your baby s birth to ensure coverage for your baby. Labs and X-rays How does my plan cover lab and X ray expenses? Lab and X-ray expenses are covered at 100% if services are rendered at a preferred hospital outpa ent department, freestanding lab facility or doctor s office. Blood work is covered whether it is for wellness or sickness. Use of an out of network lab and/or radiology provider will result in a $100 copayment to be paid at the me services are rendered for each visit. Dental Coverage Does this plan cover all dental procedures? It is strongly advised that if you are having a major dental procedure done, you ask your den st to submit a Pre Determina on before the service is performed. We will review what procedures will be performed and will advise you and your den st how much of the procedure will be covered by the plan. Your dental plan covers medically necessary dental procedures at 100%, up to an annual maximum of $5,000. If you are charged more than $5,000 per calendar year, you will be responsible for any charges above $5,000. Please note effec ve 8/1/2014 care received from an out of network dental provider will result in a $100 calendar year deduc ble for each member accessing dental care. (14)

15 Vision Benefits and Discount Program What is the Aetna Vision Care program, and how does it work? Aetna Vision Care program is a discount program available to all members. Aetna Vision Care providers will offer you both lenses and frames at a discounted rate, provided you present your member ID card at the point of purchase. You will not need to submit a claim form to receive this discount. You can locate Aetna Vision Care providers by visi ng Use the standard search func on to find Aetna Vision Care facili es near you. Is Lasik Surgery covered under the plan? No, the plan does not provide coverage for Lasik surgery. However, you are eligible for discounts through the Aetna Vision Care program. What if an Aetna Vision Care program provider has an optometrist or ophthalmologist on site? May I access care from this doctor? A provider does not always guarantee par cipa on of the resident (on site) optometrist or ophthalmologist in the Aetna PPO network. Rou ne eye exams are covered as part of your plan of benefits. As with all doctor visits, when you schedule your appointment for a rou ne eye exam, please be certain that the selected provider par cipates in the Aetna PPO network. If he/she is an Aetna PPO provider, your exam will be covered at 100%. If your provider is not an Aetna PPO provider, your exam will be covered at 100% of Reasonable and Customary Guidelines. You will be responsible for amounts over the Reasonable and Customary level. Please note: The vision hardware benefit effec ve 8/1/2014 is reimbursable up to $200 per calendar year and must meet medical necessity with a prescrip on for refrac ve lenses or contacts. Your rou ne vision exam is separate from the vision hardware benefit and will be covered 100% when using a network provider. (15)

16 How to reach Aetna Interna onal Service Center is open 24 hours a day/ 7 days a week (toll free) Arabic language is available (Inside the USA) (Outside the USA) Fax (Inside the USA) (Outside the USA) Mailing Address P.O. Box El Paso, Texas USA Urgent Mail Aetna Interna onal 4630 Woodland Corpora on BLVD Tampa, FL USA We can assist you with: Loca ng quality health care in the USA Answering ques ons regarding claims, benefit levels and coverage Processing claims in virtually any language Coordina ng reimbursement in over 180 currencies and payments through electronic reimbursement directly to bank accounts Website onal.com General Ques ons SACMmemberoutreach@sacm.org Facebook h p:// onalhealthplan TDD Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance and its affiliates (Aetna). Not all health services are covered. See plan documents for a complete descrip on of benefits, exclusions, limita ons and condi ons of coverage. Plan features are subject to change. Informa on subject to change. For more informa on about Aetna Interna onal plans, refer to onal.com. (16)