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MANAGED CHOICE® POS PLAN DISCLOSURE FORM Aetna Life

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MANAGED CHOICE® POS PLAN DISCLOSURE FORM Aetna Life MANAGED CHOICE® POS PLAN Direct access to obstetricians and gynecologists DISCLOSURE FORM If you are a female member, you may go directly to a gynecologist in our network without a referral. You may Aetna Life Insurance Company do this for diagnosis or for treatment, or if you’ve been This disclosure is not your plan of benefits, but it does referred by another doctor for gynecologic problems. describe the main features of the Managed Choice® POS plan. We provide this disclosure in compliance with the Definitions laws of the state of Georgia. While this material is believed Preferred care is care provided by: to be accurate as of the date of publication, it is subject to • A primary care physician change without notice. • A preferred care provider on the referral of the primary Your plan of benefits will be determined by your employer care physician and underwritten by the Aetna Life Insurance Company, • A nonpreferred care provider on the referral of the of Hartford, Connecticut (called Aetna®). The benefits and primary care physician, if approved by Aetna main points of the Group Contract for persons covered under your employer’s plan or benefits is detailed in the • Any health care provider for an emergency condition Booklet-Certificate, which you’ll get at a later date. In case when you can’t travel to a preferred care provider or of conflict between the Group Contract and Booklet- when you can’t get a referral by your primary care Certificate and this disclosure, the Group Contract and physician prior to treatment Booklet-Certificate will govern. A preferred care provider is a provider that has The name and address of the managed care contracted with us to provide services or supplies for a organization is: negotiated charge but only if the provider is, with our Aetna Life Insurance Company consent, included in the directory of preferred care 151 Farmington Avenue providers for: Hartford, CT 06156 • The service or supply involved • The class of employee of which you are a member MANAGED CHOICE PLAN With the Managed Choice POS plan, you can access A primary care physician (PCP) is the preferred care benefits in one of two ways: provider you selected from the list of primary care physicians in the directory. A PCP is responsible for your • You can minimize your out-of-pocket costs by visiting ongoing health care. They’re on our records as your the primary care physician (PCP) you selected and primary care physician. by getting referrals, when necessary, from your PCP. Nonpreferred care is care furnished by a health care • You also have the option to access any provider provider that is not preferred care. (preferred care or nonpreferred care provider) without a referral, for covered medical expenses. But your A nonpreferred care provider is a provider that has not out-of-pocket costs will be higher — except for contracted with us to furnish services or supplies at a emergency treatment and direct-access benefits. negotiated charge. Or it can be a preferred care provider furnishing services or supplies without the referral of a This section describes benefits for expenses incurred for primary care physician. necessary care and treatment of disease and injury. Not Certification requirements all medical expenses are covered. And some covered You must obtain certification for certain types of medical expenses are not covered in full. nonpreferred care to avoid a reduction in benefits paid for All maximums included in this plan are combined that care. Read the Patient Management Program section between preferred care and nonpreferred care, where for more details of the types of care affected, how to get applicable, unless stated otherwise. certification and how not getting certification could affect your benefits. 02.28.318.1-GA-C (3/21) 1 Member deductibles and copays 30% difference in coinsurance between preferred and The plan may contain some or all of the following nonpreferred care expenses. features. Your employer will determine the applicability The payment percentage applies after you have paid any and amount of each copay and deductible. deductible or copay amounts. • Copays — these are fees that you must pay for some Payment limits for nonpreferred care covered medical expenses. These limits apply to covered medical expenses incurred • Calendar year deductible — the amount of covered for nonpreferred care except for expenses: medical expenses you pay each calendar year before • Applied against any deductible or copay amount benefits are paid. A calendar-year deductible applies • Incurred for the effective treatment of alcoholism and to each person. drug use disorders, and for the treatment of mental • Inpatient hospital deductible — this is the amount disorders, while not confined as a full-time inpatient for inpatient hospital charges you pay for each person’s hospital stay. Covered medical expenses To be covered, the medical expense must be necessary A hospital stay for a well newborn child, with coverage for the diagnosis, care or treatment of the disease or in force, starts on the day of birth. The inpatient hospital injury as determined by Aetna. deductible and the inpatient hospital copay will not exceed the hospital’s actual charge for board and room Covered expenses include: for the first day of confinement. • Room and board and other hospital services and This inpatient hospital deductible applies to inpatient supplies for inpatient hospital stays hospital expenses incurred for nonpreferred care. • Services and supplies for outpatient hospital treatment • Emergency room deductible — a separate deductible • Services and supplies for convalescent facilities applies to each person’s visit in a hospital emergency • Home health care room. This is true unless the person is admitted to the hospital within 24 hours after a visit to a hospital • Routine physical exam emergency room. • Routine eye exam • Routine obstetric and gynecologic exams Benefits payable • Routine hearing exam After you’ve paid any applicable deductible or copay amount, the benefits under this plan are paid in a calendar • Preventive health care services (including child year at the percentage that applies to the type of covered wellness services) medical expense incurred (this is known as coinsurance). • Mammogram There are exceptions for different benefits levels, as you • Lab exams for annual chlamydia screening may see later in this disclosure form. Your benefits may • Lab exams for routine prostate-specific antigen (PSA) test vary if you don’t use a preferred care provider. • Routine Pap test We will not cover any charge for a service or supply from a preferred care provider above the provider’s negotiated • Skilled nursing care charge. In no event will you or your eligible dependents • Hospice care have to pay any such excess charge. Aetna® and the • Short-term rehabilitation preferred care provider will resolve the amount deemed excess. If any expense is covered under one type of • Prescription drugs covered medical expense, it cannot be covered under • Physicians’ services any other type. • Diagnostic lab work and X-rays Payment percentage • X-ray, radium and radioactive isotope therapy Coinsurance percentages will range from 100% to 80% • Anesthetics and oxygen for preferred care expenses and from 80% to 60% for • Rental of durable medical and surgical equipment nonpreferred care expenses, depending on the plan your employer chose. Generally, you won’t see more than a • Artificial limbs and eyes Health benefits and health insurance plans are offered by Aetna Health Inc. and/or Aetna Health Insurance Company (Aetna). 2 • Alcoholism or drug use disorders — inpatient and • Charges to the extent they are not reasonable charges, outpatient treatment as determined by Aetna • Mental disorders — inpatient and outpatient treatment • Reversal of a sterilization procedure Exclusions Pregnancy coverage We will not cover the following: We pay benefits for pregnancy-related expenses of • Services and supplies not necessary, as determined by female employees and dependents on the same basis as Aetna®, for the diagnosis, care or treatment of a disease for a disease. or an injury For inpatient hospital stays, we’ll pay benefits for care of the • Care, treatment, services, or supplies not prescribed, covered person and any newborn child for a minimum of: recommended, or approved by the attending physician • 48 hours following a vaginal delivery • Services or supplies, as determined by Aetna, that are • 96 hours following a cesarean delivery experimental or investigational If a woman is discharged earlier, benefits will be payable • Services, treatment, educational testing or training for two post-delivery home visits by a health care provider. related to learning disabilities or developmental delays Emergency care • Care furnished mainly to provide a surrounding free If you need emergency care, you’re covered, 24/7, from exposure that can worsen the person’s disease anywhere in the world. Call the local emergency hotline or injury (911). Or go to the nearest emergency facility. If a delay • Primal therapy, Rolfing, psychodrama, megavitamin would not be detrimental to your health, call your primary therapy, bioenergetic therapy, vision perception training care physician. or carbon dioxide therapy Notify your primary care physician as soon as possible • Treatment from covered health care providers, such after receiving treatment. An emergency medical as a resident physician or intern, who specialize in the condition is “one manifesting itself by acute
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