Aetna Student Health Plan Design and Benefits Summary George Washington University

Transcription

1 Quality Health Plans & Benefits Healthier Living Financial Well-Being Intelligent Solutions Aetna Student Health Plan Design and Benefits Summary George Washington University Policy Year: Policy Number: (800)

2 This is a brief description of the Student Health Plan. The Plan is available for George Washington University students and their eligible dependents. The Plan is underwritten by Aetna Life Insurance Company (Aetna). The exact provisions, including definitions, governing this insurance are contained in the Certificate of Coverage issued to you and may be viewed online at If there is a difference between this Benefit Summary and the Certificate of Coverage, the Certificate will control. GW Colonial Health Center-Medical Services The Colonial Health Center is the University's on-campus health facility. It is located at st St. NW, Ground Floor, Washington D.C, Staffed by Physicians, Nurse Practitioners, Physician Assistants, Mental Health Providers and Registered Nurses, the Facility is open weekdays from 8:30 a.m. to 5:00 p.m., during the Fall and Spring semesters. Emergency care Saturdays 9:00 a.m.-12:00 p.m., Fall & Spring Semesters. A healthcare professional is on call for medical consultations at all times. When the following services are provided at the GW Colonial Health Center (CHC) they are covered at 100% with no Copay or Deductible. Medical office s Prescription medications routinely dispensed at Health Service Routine STD screenings, (Once Annually) Physical Examinations Immunizations A yearly influenza vaccination when provided at the CHC only GW Colonial Health Center-Medical Services Annual Deductible waived for services rendered at GW Mental Health Services Office Visits covered at 100%. Group Counseling covered at 100%. Referrals to providers in the community. For more information, call the CHC Mental Health Services at (202) In the event of an emergency, call 911 or the Campus Police at (202) Policy Period Mandatory and Subsidized Graduate Assistants and Dependents 1. **Students: Coverage for all insured students enrolled for the Fall Semester that enroll in the annual plan, will become effective at 12:01 a.m. on 8/12/2018, and will terminate at 11:59 p.m. on 08/11/ New Spring Semester students: Coverage for all insured students enrolled for the Spring/Summer Semester, will become effective at 12:01 a.m. on 01/01/2019, and will terminate at 11:59 p.m. on 08/11/ Insured dependents: Coverage will become effective on the same date the insured student's coverage becomes effective, or the day after the postmarked date when the completed application and premium are sent, if later. Coverage for insured dependents terminates in accordance with the Termination Provisions described in the Master Policy. Examples include, but are not limited to: the date the student s coverage terminates, the date the dependent no longer meets the definition of a dependent. George Washington University Page 2

3 Mandatory Student Health Insurance Coverage Eligibility All Undergraduate students taking at least nine on-campus credit hours are automatically enrolled in the Plan unless proof of comparable coverage is furnished. International students on J-1 visas and F1 Visas are required to purchase the Student Health Insurance plan. Students must actively attend classes for at least the first 31 days after the date for which coverage is first purchased. The plan is also available for all non-degree seeking undergraduate students with at least 12 credit hours, and nondegree seeking graduate students with at least 9 credit hours. Post-Doctoral trainees are also eligible. You must actively attend classes for at least the first 31 days after the date your coverage becomes effective. You cannot meet this eligibility requirement if you take courses through: Home study Correspondence The internet Television (TV) If we find out that you do not meet this eligibility requirement, we are only required to refund any premium contribution minus any claims that we have paid. Rates The rates below include both premiums for the Plan underwritten by Aetna Life Insurance Company (Aetna), as well as George Washington University administrative fee. All Undergraduate, International, and all other Mandatory Students and Dependents. Annual Waiver Deadline for Students: 9/30/2018 WAIVE/ENROLLMENT INFORMATION: HOW TO WAIVE: Students the premium for the Plan will be added to your tuition bill. If you have comparable coverage and wish to waive coverage under the Plan, you must submit an Online Waiver Form. To complete the Online Waiver Form, Rates All Undergraduate, International and other Mandatory Students Spring/Summer Annual** 8/12/18-8/11/19 Fall Semester 8/12/18-12/31/18 Semester 1/1/19-8/11/19 Summer Only 5/1/19-8/11/19 Dependent Enrollment 9/30/18 9/30/18 1/31/19 5/31/19 Student $2,690 $1,075 $1,615 $753 Spouse $2,440 $950 $1,490 $682 One Child $2,440 $950 $1,490 $682 Children $4,880 $1,900 $2,980 $1,364 George Washington University Page 3

4 Voluntarily Enrolled Students and Dependents 1. **Students: Coverage for all insured students enrolled for the Fall Semester that enroll in the annual plan will become effective at 12:01 a.m. on 8/12/2018, and will terminate at 11:59 p.m. on 8/11/ New Spring Semester students: Coverage for all insured students enrolled for the Spring/Summer Semester, will become effective at 12:01 a.m. on 01/01/2019, and will terminate at 11:59 p.m. on 8/11/ Insured dependents: Coverage will become effective on the same date the insured student's coverage becomes effective, or the day after the postmarked date when the completed application and premium are sent, if later. Coverage for insured dependents terminates in accordance with the Termination Provisions described in the Master Policy. Examples include, but are not limited to: the date the student s coverage terminates, the date the dependent no longer meets the definition of a dependent. Rates The rates below include both premiums for the Plan underwritten by Aetna Life Insurance Company (Aetna), as well as George Washington University administrative fee. All Voluntary Students and Dependents Voluntarily Enrolled Students and Dependents Annual** 8/12/18-8/11/19 Rates Voluntary Graduate Students Fall** Spring/Summer 8/12/18-12/31/18 1/1/19-8/11/19 Spring Only 1/1/19-5/31/19 Summer 6/1/19-8/11/19 Enrollment Deadline 9/30/18 9/30/18 1/31/19 1/31/19 6/30/19 Student $4,103 $1, $2, $1, $ Spouse $3,826 $1, $2, $1, $ One Child $3,826 $1, $2, $1, $ Children $7,652 $2, $4, $3, $1, Annual Monthly Option: Voluntarily Enrolled Students and Dependents Annual Monthly Option: * Annual Coverage Automatic Credit Card Charge Option * 8/12/18-8/11/18 Deadline Date: 9/30/18 1. Student $ Spouse/Domestic Partner $ Child Only $ or more Children $ 638 *Please Note: Monthly payment 12 equal installments by auto-debit to credit card for coverage George Washington University Page 4

5 I understand this option is only available when paying by credit card. I authorize the monthly payment of 12 equal installments by auto-debiting my credit card. My signature provides authorization to charge my credit card for the 1 st payment at the time of enrollment and continued monthly debits for the remainder of the policy year. If for any reason my credit card does not accept the monthly debit, an alternate credit card payment must be provided within 20 days of the end of the month for which premium has been previously We will attempt to charge your credit card/bank account 3 times. For any reason, if the charge is unable to be processed, a warning letter will be sent to your address on file. If the charge fails on the 3 rd attempt, a termination letter will be sent notifying you that payment has failed and coverage will be terminated. Termination of Coverage & Re-Enrollment Options: Electing the monthly payment option requires you to pay each month. If you fail to make a payment, a termination letter will be sent describing the re-enrollment guidelines. If you terminate for lack of payment and wish to re-enroll, you must re-send the application information, a letter explaining the reason for the request for an exception request and premium payment for the remainder of the plan year. (A petition to be reinstated is not a guarantee of reinstatement of the policy) Voluntary Student Coverage Who is eligible? You are eligible if you are a: All part-time undergraduate and graduate students matriculated in a degree program at The George Washington University, and who actively attend classes for at least the first 31 days, after the date when coverage becomes effective are eligible to enroll. The plan is also available for all non-degree seeking undergraduate students with at least 12 credit hours, and non-degree seeking graduate students with at least 9 credit hours. Post-Doctoral trainees are also eligible. You must actively attend classes for at least the first 31 days after the date your coverage becomes effective. You cannot meet this eligibility requirement if you take courses through: Home study Correspondence The internet Television (TV) If we find out that you do not meet this eligibility requirement, we are only required to refund any premium contribution minus any claims that we have paid. Enrollment To enroll online or obtain an enrollment application for voluntary coverage, log on to and search for your school, then click on Enroll to download the appropriate form. If you withdraw from school within the first 31 days of a coverage period, you will not be covered under the Policy and the full premium will be refunded, less any claims paid. After 31 days, you will be covered for the full period that you have paid the premium for, and no refund will be allowed. (This refund policy will not apply if you withdraw due to a covered Accident or Sickness.) George Washington University Page 5

6 Dependent Coverage Eligibility Covered students may also enroll their lawful spouse, domestic partner (same-sex, opposite sex), and dependent children up to the age of 26. Enrollment To enroll the dependent(s) of a covered student, please complete the Enrollment Form by ing selecting the school name, and clicking on the Plans & Products Offered to You link on the left hand side of the screen, or by calling customer service at (800) and requesting that an Enrollment Form be sent in the mail. Please refer to the Coverage Periods section of this document for coverage dates and deadline dates. Dependent enrollment applications will not be accepted after the enrollment deadline, unless there is a significant life change that directly affects their insurance coverage. (An example of a significant life change would be loss of health coverage under another health plan.) The completed Enrollment Form and premium must be sent to Aetna Student Health. Important note regarding coverage for a newborn infant or newly adopted child: Your newborn child is covered on your health plan for the first 31 days from the moment of birth. To keep your newborn covered, you must notify us (or our agent) of the birth and pay any required premium contribution during that 31 day period. You must still enroll the child within 31 days of birth even when coverage does not require payment of an additional premium contribution for the newborn. If you miss this deadline, your newborn will not have health benefits after the first 31 days. If your coverage ends during this 31 day period, then your newborn s coverage will end on the same date as your coverage. This applies even if the 31 day period has not ended. A child that you, or that you and your spouse, domestic partner adopts or is placed with you for adoption, is covered on your plan for the first 31 days after the adoption or the placement is complete. To keep your child covered, we must receive your completed enrollment information within 31 days after the adoption or placement for adoption. You must still enroll the child within 31 days of the adoption or placement for adoption even when coverage does not require payment of an additional premium contribution for the child. If you miss this deadline, your adopted child or child placed with you for adoption will not have health benefits after the first 31 days. If your coverage ends during this 31 day period, then coverage for your adopted child or child placed with you for adoption will end on the same date as your coverage. This applies even if the 31 day period has not ended. If you need information or have general questions on dependent enrollment, call Member Services at (800) Medicare Eligibility Notice You are not eligible for health coverage under this student policy if you have Medicare at the time of enrollment in this student plan. If you obtain Medicare after you enrolled in this student plan, your health coverage under this plan will not end. As used here, have Medicare means that you are entitled to benefits under Part A (receiving free Part A) or enrolled in Part B or Premium Part A. George Washington University Page 6

7 In-network Provider Network Aetna Student Health offers Aetna s broad network of In-network Providers. You can save money by seeing In-network Providers because Aetna has negotiated special rates with them, and because the Plan s benefits are better. If you need care that is covered under the Plan but not available from an In-network Provider, contact Member Services for assistance at the toll-free number on the back of your ID card. In this situation, Aetna may issue a pre-approval for you to receive the care from an Out-of-network Provider. When a pre-approval is issued by Aetna, the benefit level is the same as for In-network Providers. Pre-certification You need pre-approval from us for some eligible health services. Pre-approval is also called pre-certification. Pre-certification for medical services and supplies In-network care Your in-network physician is responsible for obtaining any necessary pre-certification before you get the care. If your innetwork physician doesn't get a required pre-certification, we won't pay the provider who gives you the care. You won't have to pay either if your in-network physician fails to ask us for pre-certification. If your in-network physician requests pre-certification and we refuse it, you can still get the care but the plan won t pay for it. You will find additional details on requirements in the Certificate of Coverage. Out-of-network care When you go to an out-of-network provider, it is your responsibility to obtain pre-certification from us for any services and supplies on the pre-certification list. If you do not pre-certify, your benefits may be reduced, or the plan may not pay any benefits. Refer to your schedule of benefits for this information. The list of services and supplies requiring precertification appears later in this section. Pre-certification call Pre-certification should be secured within the timeframes specified below. To obtain pre-certification, call Member Services at the toll-free number on your ID card. This call must be made: Non-emergency admissions: An emergency admission: An urgent admission: Outpatient non-emergency services requiring pre-certification: Delivery: You, your physician or the facility will need to call and request precertification at least 14 days before the date you are scheduled to be admitted. You, your physician or the facility must call within 48 hours or as soon as reasonably possible after you have been admitted. You, your physician or the facility will need to call before you are scheduled to be admitted. An urgent admission is a hospital admission by a physician due to the onset of or change in an illness, the diagnosis of an illness, or an injury. You or your physician must call at least 14 before the outpatient care is provided, or the treatment or procedure is scheduled. You, your physician, or the facility must call within 48 hours of the birth or as soon thereafter as possible. No penalty will be applied for the first 48 hours after delivery for a routine delivery and 96 hours for a cesarean delivery. George Washington University Page 7

8 We will provide a written notification to you and your physician of the pre-certification decision, where required by state law. If your pre-certified services are approved, the approval is valid for 30 as long as you remain enrolled in the plan. If you require an extension to the services that have been pre-certified, you, your physician, or the facility will need to call us at the number on your ID card as soon as reasonably possible, but no later than the final authorized day. If pre-certification determines that the stay or outpatient services and supplies are not covered benefits, the notification will explain why and how you can appeal our decision. You or your provider may request a review of the pre-certification decision. See the When you disagree - claim decisions and appeals procedures section of Certificate of Coverage. What if you don t obtain the required pre-certification? If you don t obtain the required pre-certification: Your benefits may be reduced, or the plan may not pay any benefits. See the schedule of benefits Precertification penalty section. You will be responsible for the unpaid balance of the bills. Any additional out-of-pocket expenses incurred will not count toward your deductibles or maximum out-ofpocket limits. What types of services and supplies require pre-certification? Pre-certification is required for the following types of services and supplies: Inpatient services and supplies ART services Obesity (bariatric) surgery Stays in a hospice facility Stays in a hospital Stays in a rehabilitation facility Stays in a residential treatment facility for treatment of mental disorders and substance abuse Stays in a skilled nursing facility Outpatient services and supplies Applied behavior analysis Certain prescription drugs and devices* Complex imaging Comprehensive infertility services Cosmetic and reconstructive surgery Emergency transportation by airplane Intensive outpatient program (IOP) mental disorder and substance abuse diagnoses Kidney dialysis Knee surgery Medical injectable drugs, (immunoglobulins, growth hormones, multiple sclerosis medications, osteoporosis medications, botox, hepatitis C medications)* Outpatient back surgery not performed in a physician s office Outpatient detoxification Partial hospitalization treatment mental disorder and substance abuse diagnoses Private duty nursing services Psychological testing/neuropsychological testing Sleep studies Transcranial magnetic stimulation (TMS) Wrist surgery George Washington University Page 8

9 *For a current listing of the prescription drugs and medical injectable drugs that require pre-certification, contact Member Services by calling the toll-free number on your ID card in the How to contact us for help section or by logging onto the Aetna website at Coordination of Benefits (COB) Some people have health coverage under more than one health plan. If you do, we will work together with your other plan(s) to decide how much each plan pays. This is called coordination of benefits (COB). Here s how COB works When this is the primary plan, we will pay your medical claims first as if the other plan does not exist When this is the secondary plan, we will pay benefits after the primary plan and will reduce the payment based on any amount the primary plan paid We will never pay an amount that, together with payments from your other coverage, add up to more than 100% of the allowable submitted expenses For more information about the Coordination of Benefits provision, including determining which plan is primary and which is secondary, you may call the Member Services telephone number shown on your ID card. A complete description of the Coordination of Benefits provision is contained in the Policy issued to George Washington University, and may be viewed online at Description of Benefits The Plan excludes coverage for certain services (referred to as exceptions in the certificate of coverage) and has limitations on the amounts it will pay. While this Plan Design and Benefit Summary document will tell you about some of the important features of the Plan, other features may be important to you and some may further limit what the Plan will pay. To look at the full Plan description, which is contained in the Certificate of Coverage issued to you, go to If any discrepancy exists between this Benefit Summary and the Certificate of Coverage, the Certificate will control. This Plan will pay benefits in accordance with any applicable District of Columbia Insurance Law(s). Metallic Level: Gold, 81.71% Tested at. Policy year deductible In-network coverage Out-of-network coverage You have to meet your policy year deductible before this plan pays for benefits. Student $300 per policy year $3,000 per policy year Spouse $300 per policy year $3,000 per policy year Each child $300 per policy year $3,000 per policy year Family None None PRESCRIBED MEDICINES EXPENSE Student $100 per policy year Spouse $100 per policy year Each child $100 per policy year Note: When the plan includes both a medical policy year deductible and an outpatient prescription drug policy year deductible, the combined policy year deductible amounts for select care coverage and in-network coverage will not be more than $7,350 per person or $14,700 per family per policy year. Policy year deductible waiver George Washington University Page 9

10 Policy year deductible In-network coverage Out-of-network coverage The policy year deductible is waived for all of the following eligible health services: In-network care for Preventive care and wellness Pap Smear Screening Expense; and Mammogram Expense. In addition to state and federal requirements for waiver of the policy year deductible, the plan will waive the policy year deductible for: Preferred Care Laboratory and X-Ray Expense; Preferred Care Allergy Testing Expense; Preferred Care Diagnostic Testing For Learning Disabilities Expense; Preferred Care Maternity Expense; Preferred Care Gynecology; Preferred Care Outpatient Treatment of Mental Health; Preferred Care Pediatric Preventive Dental; and Preferred and Non-Preferred Care Pediatric Vision Services. Per or admission Deductibles do not apply towards satisfying the Policy Year Deductible. This Policy Year Deductible and the Prescribed Medicine Expense Deductible do not apply towards satisfying each other. Maximum out-of-pocket limits Maximum out-of-pocket limit per policy year Student $6,350 per policy year $15,000 per policy year Spouse $6,350 per policy year $15,000 per policy year Each child $6,350 per policy year $15,000 per policy year Family $12,700 per policy year $30,000 per policy year Pre-certification covered benefit penalty This only applies to out-of-network coverage: The certificate of coverage contains a complete description of the precertification program. You will find details on pre-certification requirements in the Medical necessity and precertification requirements section. Failure to pre-certify your eligible health services when required will result in the following benefit penalties: A $500 benefit penalty will be applied separately to each type of eligible health services. The additional percentage or dollar amount of the recognized charge which you may pay as a penalty for failure to obtain pre-certification is not a covered benefit, and will not be applied to the policy year deductible amount or the maximum out-of-pocket limit, if any. The coinsurance listed in the schedule of benefits below reflects the plan coinsurance percentage. This is the coinsurance amount that the plan pays. You are responsible for paying any remaining coinsurance. George Washington University Page 10

11 Eligible health services In-network coverage Out-of-network coverage Preventive care and wellness Routine physical exams Performed at a physician s office 100% (of the negotiated charge) per No copayment or policy year deductible applies Covered persons through age 21: Maximum age and limits per policy year Subject to any age and limits provided for in the comprehensive guidelines supported by the American Academy of Pediatrics/Bright Futures//Health Resources and Services Administration guidelines for children and adolescents. Covered persons age 22 and over: Maximum s per policy year Preventive care immunizations Performed in a facility or at a physician's office For details, contact your physician or Member Services by logging onto your Aetna Navigator secure website at or calling the toll-free number on your ID card % (of the negotiated charge) per. No copayment or policy year deductible applies Maximums Subject to any age limits provided for in the comprehensive guidelines supported by Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention For details, contact your physician or Member Services by logging onto your Aetna Navigator secure website at or calling the toll-free number on your ID card. Well woman preventive s Routine gynecological exams (including Pap smears and cytology tests) Performed at a physician s, 100% (of the negotiated charge) per obstetrician (OB), gynecologist No copayment or policy year deductible (GYN) or OB/GYN office applies Maximums Subject to any age limits provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Preventive screening and counseling services Obesity and/or healthy diet 100% (of the negotiated charge) per counseling office s No copayment or policy year deductible applies George Washington University Page 11

12 Eligible health services In-network coverage Out-of-network coverage Preventive screening and counseling services (continued) Maximum s per policy year (This maximum applies only to covered persons age 22 and older.) Misuse of alcohol and/or drugs counseling office s 26 s (however, of these only 10 s will be allowed under the plan for healthy diet counseling provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet-related chronic disease) 100% (of the negotiated charge) per No copayment or policy year deductible applies Maximum s per policy year Use of tobacco products counseling office s Maximum s per policy year Depression screening counseling office s Maximum s per policy year Sexually transmitted infection counseling office s Maximum s per policy year Genetic risk counseling for breast and ovarian cancer counseling office s 100% (of the negotiated charge) per No copayment or policy year deductible applies 100% (of the negotiated charge) per No copayment or policy year deductible applies 5 s 8 s 1 100% (of the negotiated charge) per No copayment or policy year deductible applies 2 s 100% (of the negotiated charge) per No copayment or policy year deductible applies Routine cancer screenings performed at a physician s office, specialist s office or facility. Routine cancer screenings 100% (of the negotiated charge) per No copayment or policy year deductible applies 100% (of the recognized charge) per Maximums Subject to any age; family history; and frequency guidelines as set forth in the most current: Evidence-based items that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force; and The comprehensive guidelines supported by the Health Resources and Services Administration. For details, contact your physician or Member Services by logging onto your Aetna Navigator secure website at or calling the toll-free number on your ID card. George Washington University Page 12

13 Eligible health services In-network coverage Out-of-network coverage Routine cancer screenings performed at a physician s office, specialist s office or facility (continued) Lung cancer screening 1 screening every 12 months* maximums *Important note: Any lung cancer screenings that exceed the lung cancer screening maximum above are covered under the Outpatient diagnostic testing section. Prenatal care services (provided by a physician, an obstetrician (OB), gynecologist (GYN), and/or OB/GYN) Preventive care services only 100% (of the negotiated charge) per No copayment or policy year deductible applies Important note: You should review the Maternity care and Well newborn nursery care sections. They will give you more information on coverage levels for maternity care under this plan. Comprehensive lactation support and counseling services Lactation counseling services - 100% (of the negotiated charge) per facility or office s No copayment or policy year deductible applies Lactation counseling services 6 s maximum s per policy year either in a group or individual setting Important note: Any s that exceed the lactation counseling services maximum are covered under the Physicians and other health professionals section. Breast pump supplies and accessories 100% (of the negotiated charge) per No copayment or policy year deductible applies Maximums An electric breast pump (non-hospital grade, cost is covered by your plan once every three years) or A manual breast pump (cost is covered by your plan once per pregnancy) If an electric breast pump was purchased within the previous three year period, the purchase of another electric breast pump will not be covered until a three year period has elapsed since the last purchase. Family planning services female contraceptives Female contraceptive 100% (of the negotiated charge) per counseling services No copayment or policy year deductible office applies Contraceptives (prescription drugs and devices) Female contraceptive 100% (of the negotiated charge) per prescription drugs and devices No copayment or policy year deductible provided, administered, or applies removed, by a physician during an office George Washington University Page 13

14 Eligible health services In-network coverage Out-of-network coverage Female voluntary sterilization Inpatient provider services Outpatient provider services 100% (of the negotiated charge) per No copayment or policy year deductible applies 100% (of the negotiated charge) per No copayment or policy year deductible applies Physicians and other health professionals Physician and specialist services Office hours s 80% (of the negotiated charge) per (non-surgical and non-preventive care by a physician and specialist) Telemedicine consultation By a physician or specialist Allergy testing and treatment Allergy testing performed at a physician s or specialist s office Allergy injections treatment performed at a physician s, or specialist office Allergy sera and extracts administered via injection at a physician s or specialist s office benefit benefit benefit benefit Physician and specialist - inpatient surgical services Inpatient surgery performed 80% (of the negotiated charge) per during your stay in a hospital or birthing center by a surgeon Anesthetist 80% (of the negotiated charge) per benefit and the place where the service is benefit and the place where the service is benefit and the place where the service is benefit and the place where the service is Surgical assistant 80% (of the negotiated charge) per Physician and specialist - outpatient surgical services Outpatient surgery performed 80% (of the negotiated charge) per at a physician s or specialist s office or outpatient department of a hospital or surgery center by a surgeon George Washington University Page 14

15 Eligible health services In-network coverage Out-of-network coverage In-hospital non-surgical physician services In-hospital non-surgical 80% (of the negotiated charge) per physician services Consultant services (non-surgical and non-preventive) Office hours s (nonsurgical and non-preventive care) Telemedicine consultation by a consultant Second surgical opinion 80% (of the negotiated charge) per benefit benefit Alternatives to physician office s Walk-in clinic s(nonemergency ) 80% (of the negotiated charge) per Hospital and other facility care Inpatient hospital 80% (of the negotiated charge) per (room and board) and other miscellaneous services and supplies) Subject to semi-private room rate unless intensive care unit required Room and board includes intensive care For physician charges, refer to the Physician and specialist inpatient surgical services benefit Preadmission testing benefit Alternatives to hospital stays Outpatient surgery (facility charges) Facility charges for surgery 80% (of the negotiated charge) per performed in the outpatient department of a hospital or surgery center For physician charges, refer to the Physician and specialist - outpatient surgical services benefit benefit and the place where the service is benefit and the place where the service is benefit and the place where the service is George Washington University Page 15

16 Eligible health services In-network coverage Out-of-network coverage Home health care Outpatient Outpatient private duty nursing 80% (of the negotiated charge) per 80% (of the negotiated charge) per 80% (of the recognized charge) per Hospice care Inpatient facility (room and board and other miscellaneous services and supplies) Outpatient Skilled nursing facility Inpatient facility (room and board and miscellaneous inpatient care services and supplies) Subject to semi-private room rate unless intensive care unit is required Room and board includes intensive care 80% (of the negotiated charge) per 80% (of the negotiated charge) per 80% (of the negotiated charge) per Emergency services and urgent care Emergency services Hospital emergency room *Includes complex imaging services, lab work and radiological services performed during a hospital emergency room, and any surgery which results from the hospital emergency room $100 copayment then the plan pays 80% (of the balance of the negotiated charge) per Paid the same as in-network coverage Non-emergency care in a hospital emergency room Not covered Not covered George Washington University Page 16

17 Eligible health services In-network coverage Out-of-network coverage Emergency services (continued) Important note: As out-of-network providers do not have a contract with us the provider may not accept payment of your cost share, (copayment/coinsurance), as payment in full. You may receive a bill for the difference between the amount billed by the provider and the amount paid by this plan. If the provider bills you for an amount above your cost share, you are not responsible for paying that amount. You should send the bill to the address listed on the back of your ID card, and we will resolve any payment dispute with the provider over that amount. Make sure the ID card number is on the bill. A separate hospital emergency room copayment/coinsurance will apply for each to an emergency room. If you are admitted to a hospital as an inpatient right after a to an emergency room, your emergency room copayment/coinsurance will be waived and your inpatient copayment/coinsurance will apply. Covered benefits that are applied to the hospital emergency room copayment/coinsurance cannot be applied to any other copayment/coinsurance under the plan. Likewise, a copayment/coinsurance that applies to other covered benefits under the plan cannot be applied to the hospital emergency room copayment/coinsurance. Separate copayment/coinsurance amounts may apply for certain services given to you in the hospital emergency room that are not part of the hospital emergency room benefit. These copayment/coinsurance amounts may be different from the hospital emergency room copayment/coinsurance. They are based on the specific service given to you. Services given to you in the hospital emergency room that are not part of the hospital emergency room benefit may be subject to copayment/coinsurance amounts that are different from the hospital emergency room copayment/coinsurance amounts. Urgent care Urgent medical care provided by an urgent care provider Does not include complex imaging services, lab work and radiological services performed during an urgent medical care 80% (of the negotiated charge) per Non-urgent use of urgent care provider Examples of non-urgent care are: Routine or preventive care (this includes immunizations) Follow-up care Physical therapy Elective treatment Any diagnostic lab work and radiological services which are not related to the treatment of the urgent condition. Not covered Not covered George Washington University Page 17

18 Eligible health services In-network coverage Out-of-network coverage Pediatric dental care (Limited to covered persons through the end of the month in which the person turns age 19) Type A services 100% (of the negotiated charge) per No copayment or deductible applies 70% (of the recognized charge) per Type B services Type C services Orthodontic services 70% (of the negotiated charge) per No copayment or deductible applies 50% (of the negotiated charge) per No copayment or deductible applies 50% (of the negotiated charge) per No copayment or deductible applies 50% (of the recognized charge) per 50% (of the recognized charge) per 50% (of the recognized charge) per Dental emergency treatment benefit received Specific conditions Birthing center (facility charges) Inpatient (room and board Paid at the same cost-sharing as hospital and other miscellaneous care. services and supplies) Diabetic services and supplies (including equipment and training) Diabetic services and supplies (including equipment and training) Impacted wisdom teeth Impacted wisdom teeth benefit received 100% (of the negotiated charge) per Accidental injury to sound natural teeth Accidental injury to sound 100% (of the negotiated charge) per natural teeth benefit and the place where the service is Paid at the same cost-sharing as hospital care. benefit and the place where the service is received 100% (of the recognized charge) per 100% (of the recognized charge) per Temporomandibular joint dysfunction (TMJ) and craniomandibular joint dysfunction (CMJ) treatment TMJ and CMJ treatment benefit benefit and the place where the service is George Washington University Page 18

19 Eligible health services In-network coverage Out-of-network coverage Dermatological treatment Dermatological treatment Maternity care Maternity care (includes delivery and postpartum care services in a hospital or birthing center) Well newborn nursery care in a hospital or birthing center benefit benefit 80% (of the negotiated charge) per benefit and the place where the service is benefit and the place where the service is Note: The per admission copayment amount and/or policy year deductible for newborns will be waived for nursery charges for the duration of the newborn s initial routine facility stay. The nursery charges waiver will not apply for non-routine facility stays. Pregnancy complications Inpatient (room and board and other miscellaneous services and supplies) Subject to semi-private room rate unless intensive care unit required Room and board includes intensive care benefit Family planning services other Voluntary sterilization for benefit males Inpatient physician or specialist surgical services Voluntary sterilization for males Outpatient physician or specialist surgical services benefit Gender reassignment (sex change) treatment Surgical, hormone replacement benefit therapy, and counseling treatment benefit and the place where the service is benefit and the place where the service is benefit and the place where the service is benefit and the place where the service is Important Note: Just log into your Aetna Navigator secure website at for detailed information about this covered benefit, including eligibility requirements in Aetna s clinical policy bulletin #0615. You can also call Member Services at the toll-free number on the back of your ID card. George Washington University Page 19

20 Eligible health services In-network coverage Out-of-network coverage Autism spectrum disorder Autism spectrum disorder treatment (includes physician and specialist office s, diagnosis and testing) Physical, occupational, and speech therapy associated with diagnosis of autism spectrum disorder Applied behavior analysis* benefit received benefit received benefit received benefit and the place where the service is received benefit and the place where the service is received benefit and the place where the service is received *Important note: Applied behavior analysis requires pre-certification by Aetna. Your in-network provider is responsible for obtaining pre-certification. You are responsible for obtaining pre-certification when you use an out-of-network provider. Mental health treatment Mental health treatment inpatient Inpatient hospital mental 80% (of the negotiated charge) per disorders treatment (room and board and other miscellaneous hospital services and supplies) Inpatient residential treatment facility mental disorders treatment (room and board and other miscellaneous residential treatment facility services and supplies) Subject to semi-private room rate unless intensive care unit is required Mental disorder room and board intensive care Outpatient mental disorders treatment office s to a physician or behavioral health provider (includes telemedicine cognitive behavioral therapy consultations) 80% (of the negotiated charge) per George Washington University Page 20

21 Eligible health services In-network coverage Out-of-network coverage Mental health treatment inpatient (continued) Other outpatient mental 80% (of the negotiated charge) per disorders treatment (includes skilled behavioral health services in the home) Partial hospitalization treatment (at least 6 hours, but less than 24 hours per day of clinical treatment) Intensive Outpatient Program (at least 2 hours per day and at least 8 hours per week of clinical treatment) Substance abuse related disorders treatment-inpatient Inpatient hospital substance 80% (of the negotiated charge) per abuse detoxification (room and board and other miscellaneous hospital services and supplies) Inpatient hospital substance abuse rehabilitation (room and board and other miscellaneous hospital services and supplies) Inpatient residential treatment facility substance abuse (room and board and other miscellaneous residential treatment facility services and supplies) Subject to semi-private room rate unless intensive care unit is required Substance abuse room and board intensive care Substance abuse related disorders treatment-outpatient: detoxification and rehabilitation Outpatient substance abuse office s to a physician or behavioral health provider (includes telemedicine cognitive behavioral therapy consultations) 80% (of the negotiated charge) per George Washington University Page 21

22 Eligible health services In-network coverage Out-of-network coverage Substance abuse related disorders treatment-outpatient: detoxification and rehabilitation (continued) Other outpatient substance abuse services (includes skilled 80% (of the negotiated charge) per behavioral health services in the home) Partial hospitalization treatment (at least 6 hours, but less than 24 hours per day of clinical treatment) Intensive Outpatient Program (at least 2 hours per day and at least 8 hours per week of clinical treatment) Reconstructive surgery and supplies Reconstructive surgery and benefit supplies (includes reconstructive breast surgery) Eligible health services Transplant services Inpatient and outpatient transplant facility services Inpatient and outpatient transplant physician and specialist services Transplant services-travel and lodging Lifetime Maximum payable for Travel and Lodging Expenses for any one transplant, including tandem transplants Maximum payable for Lodging Expenses per IOE patient Maximum payable for Lodging Expenses per companion Treatment of infertility Basic infertility services Inpatient and outpatient care - basic infertility In-network coverage (IOE facility) In-network coverage (Non-IOE facility) benefit and the place where the service is Out-of-network coverage benefit benefit Covered Covered Covered $10,000 $10,000 $10,000 $50 per night $50 per night $50 per night $50 per night $50 per night $50 per night benefit benefit and the place where the service is George Washington University Page 22

23 Eligible health services In-network coverage Out-of-network coverage Specific therapies and tests Outpatient diagnostic testing Diagnostic complex imaging services performed in the outpatient department of a hospital or other facility Diagnostic lab work and radiological services performed in a physician s office, the outpatient department of a hospital or other facility Chemotherapy Chemotherapy 80% (of the negotiated charge) per 80% (of the negotiated charge) per 80% (of the negotiated charge) per Outpatient infusion therapy Outpatient infusion therapy performed in a covered person s home, physician s office, outpatient department of a hospital or other facility Outpatient radiation therapy Outpatient radiation therapy benefit 80% (of the negotiated charge) per benefit and the place where the service is Outpatient respiratory therapy Respiratory therapy 80% (of the negotiated charge) per Transfusion or kidney dialysis of blood Transfusion or kidney dialysis benefit of blood received Short-term cardiac and pulmonary rehabilitation services Cardiac rehabilitation 80% (of the negotiated charge) per benefit and the place where the service is received Pulmonary rehabilitation 80% (of the negotiated charge) per George Washington University Page 23

24 Eligible health services In-network coverage Out-of-network coverage Short-term rehabilitation and habilitation therapy services Outpatient physical, 80% (of the negotiated charge) per occupational, speech, and cognitive therapies Combined for short-term rehabilitation services and habilitation therapy services Chiropractic services Chiropractic services 80% (of the negotiated charge) per Maximum s per policy year unlimited Diagnostic testing for learning disabilities Diagnostic testing for learning benefit disabilities Specialty prescription drugs (Purchased and injected or infused by your provider in an outpatient setting) Specialty prescription drugs benefit purchased and injected or or the place where the service is infused by your provider in an outpatient setting benefit and the place where the service is benefit or the place where the service is Other services and supplies Acupuncture in lieu of anesthesia Emergency ground, air, and water ambulance Clinical trial therapies Clinical trial (routine patient costs) Durable medical and surgical equipment benefit received 100% (of the negotiated charge) per benefit benefit 80% (of the negotiated charge) per benefit and the place where the service is received 100% (of the recognized charge) per benefit and the place where the service is benefit and the place where the service is 80% (of the recognized charge) per George Washington University Page 24

25 Eligible health services In-network coverage Out-of-network coverage Other services and supplies (continued) Enteral formulas and 80% (of the negotiated charge) per nutritional supplements Osteoporosis (non-preventive care) Prosthetic devices All other prosthetic devices Hearing aids and exams Hearing aid exams Hearing aids benefit 80% (of the negotiated charge) per 80% (of the negotiated charge) per 80% (of the negotiated charge) per benefit and the place where the service is Hearing aids maximum per One hearing aid per ear every policy year ear Podiatric (foot care) treatment Physician and Specialist nonroutine foot care treatment benefit benefit and the place where the service is Vision care Pediatric vision care (Limited to covered persons through the end of the month in which the person turns age 19) Pediatric routine vision exams (including refraction) Performed by a legally qualified ophthalmologist or optometrist Maximum s per policy year 100% (of the negotiated charge) per 70% (of the recognized charge) per No policy year deductible applies No policy year deductible applies 1 Pediatric comprehensive low vision evaluations Performed by a legally qualified benefit ophthalmologist or optometrist Maximum One comprehensive low vision evaluation every policy year benefit and the place where the service is George Washington University Page 25

26 Eligible health services In-network coverage Out-of-network coverage Pediatric vision care services and supplies Eyeglass frames, prescription 100% (of the negotiated charge) per 70% (of the recognized charge) per lenses or prescription contact No policy year deductible applies lenses No policy year deductible applies Maximum number of eyeglass frames per policy year Maximum number of prescription lenses per policy year Maximum number of prescription contact lenses per policy year (includes nonconventional prescription contact lenses and aphakic lenses prescribed after cataract surgery) Office for fitting of contact lenses One set of eyeglass frames One pair of prescription lenses Daily disposables: up to 3 month supply Extended wear disposable: up to 6 month supply Non-disposable lenses: one set 100% (of the negotiated charge) per No policy year deductible applies 70% (of the recognized charge) per No policy year deductible applies Optical devices Maximum number of optical devices per policy year One optical device benefit benefit and the place where the service is Important note: Refer to the Vision care section in the certificate of coverage for the explanation of these vision care supplies. As to coverage for prescription lenses in a policy year, this benefit will cover either prescription lenses for eyeglass frames or prescription contact lenses, but not both. Coverage does not include the office for the fitting of prescription contact lenses. Outpatient prescription drugs Policy year deductible and copayment/coinsurance waiver for risk reducing breast cancer The policy year deductible and the per prescription copayment/coinsurance will not apply to risk reducing breast cancer prescription drugs when obtained at a retail in-network, pharmacy. This means that such risk reducing breast cancer prescription drugs are paid at 100%. Policy year deductible and copayment/coinsurance waiver for tobacco cessation prescription and overthe-counter drugs The policy year deductible and the per prescription copayment/coinsurance will not apply to the first two 90-day treatment regimens per policy year for tobacco cessation prescription drugs and OTC drugs when obtained at a retail in-network pharmacy. This means that such prescription drugs and OTC drugs are paid at 100%. Your policy year deductible and any prescription copayment/coinsurance will apply after those two regimens per policy year have been exhausted. George Washington University Page 26