SACM Student Guide - …aetnaglobalbenefitsmarketing.com/AGBEmail/SACM/SACM_Students_Guide...serve...

( ) Aetna International Member Services - Toll Free - 24 hours, 7 days a week: 1-866-236-1038

SACM Student Guide

Answers to your questions about your Aetna International plan

Mission Statement: Onsite SACM Team, Fairfax, VA

As an ambassador to health care in the U.S., Aetna International's Onsite Service and Support Team’s function 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 collaboration with SACM, Aetna network providers and U.S. learning institutions, we provide access to health care while promoting health education for healthy living. This enhances the student scholarship experience in support of the SACM mission.

(2) Aetna International Member Services - Toll Free - 24 hours, 7 days a week: 1-866-236-1038

Table of Contents Health Insurance General Information 3 Student Medical Plan Benefits 4 Applying for your Health Insurance ID Card 7 How to Find a Health Care Provider 18 Why to Find a Primary Care Doctor 18 How to Access Emergency & Urgent Care 19 How to File a Claim 20 Useful Questions & Answers 21 How to Contact Us 24

We Focus on Your Health We Focus on Your Health We Focus on Your Health You Focus on Your StudyYou Focus on Your StudyYou Focus on Your Study Your health and wellness play an important role in your everyday life. We know how important it is to receive quality and timely medical care, no matter when or where you need it. That’s where we come in. Aetna International is here to make sure you have ac-cess to the care that you need in the event of a routine or emergency medical situation. Our service model places you at the center of everything we do, ensuring that you receive the care you need with ultimate con-venience. With Aetna International as your health benefits provid-er, you can rest assured that you will have reliable ser-vices 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 time for you to experience the Aetna International difference. Within this guide, you will find valuable information on the programs and services available to you as an Aetna International member. We encourage you to read these materials to learn about your plan and how to use your benefits.


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 stu-dents 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 ser-vices, available doctors and hospitals, deductibles to meet, and copay-ments 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 Aet-na network is one of America’s largest health care networks, with over 1 million U.S. network pro-viders. Your medical plan includes: – 100% coverage anywhere in the world ( Applies in Aetna network in US only) – 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 1‐866‐236‐1038.

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Note: This is not evidence of coverage. You must enroll and be accepted for coverage with the Coverage Administrator before the benefits described in this document

will be effective. In case of a discrepancy between the Plan Documents, and this document, the Plan Documents will determine the Plan of Benefits. As used herein, the

term "Plan Documents" includes, but is not limited to, the Booklet, Summary of Coverage and any Booklet Amendments/Riders. For further details refer to your Plan

Documents. 10/25/2011

Group Insurance Plan of Benefits for Cultural Mission to the Embassy of Saudi Arabia

(Control #299678) insured by Aetna International

Eligibility Provision

Students Any Saudi national enrolled in a scholarly program in the United States pursuant to a valid student visa issued by the U.S.

Dependent Wife or husband, dependent children and sponsored dependents deemed eligible by SACM.

PPO

In the U.S.

PLAN FEATURES OUTSIDE THE U.S. Preferred Benefits (In-Network)

Non-Preferred Benefits (Out-of-Network)

Individual Deductible None None None

Individual Payment Limit None None None

Lifetime Year Maximum $2,000,000

Plan Payment Percentages

Hospital Services Inpatient 100% 100% 100%

Outpatient 100% 100% 100%

Private Room Limit The institution's semiprivate rate

Pre-certification Penalty No Penalty No Penalty No Penalty

Accompaniment of a Minor while Inpatient

100% 100% 100%

Non-Emergency Use of the Emergency Room

100% 100% after $50 copay (Waived if Confined)

100% after $50 copay (Waived if Confined)

Emergency Room 100% 100% 100%

Urgent Care 100% 100% 100%

Physician Services

Primary Care Physician Office Visit

100% 100% 100%

Specialist Office Visit 100% 100% 100%

Mental Health Services

Mental Health Inpatient Coverage 100% 100% 100%

Mental Health Outpatient 100% 100% 100% Coverage

Alcohol/Drug Abuse Services

Substance Abuse Inpatient 100% 100% 100% Coverage

Substance Abuse Outpatient 100% 100% 100% Coverage

Other Services Skilled Nursing Facility (Unlimited days per calendar year)

100% 100% 100%

Home Health Care (Includes Private Duty Nursing) (Unlimited visits per calendar year)

100% 100% 100%

Hospice Care Facility Inpatient (30 days lifetime maximum)

100% 100% 100%

Hospice Care Facility Outpatient ($5,000 lifetime maximum)

100% 100% 100%

Spinal Disorder Treatment (Unlimited visits per calendar year)

100% 100% 100%

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Effective Date: September 1, 2011 PPO

In the U.S.



Plan Payment Percentages

Other Services

Short Term Rehabilitation 100% 100% 100%

(Includes coverage for Occupational, Physical and Speech Therapies; 60 combined maximum visits per calendar year)

Diagnostic Outpatient X-ray 100% 100% 100%

Diagnostic Outpatient Lab 100% 100% 100%

Bariatric Surgery (Unlimited per lifetime maximum)

100% 100% 100%

Routine Hearing Exam (Includes one routine exam every 2 years.)

100% 100% 100%

Hearing Aids ($3,500 maximum every 12 months)

100% 100%` 100%

Circumcision for newborn male 100% 100% 100%

Ear piercing for newborn female 100% 100% 100%

Ambulance (Emergency only)

100% 100% 100%

Temporomandibular Joint (TMJ) 100% 100% 100% Disorder (Subject to pre-certification) (Subject to $5,000 maximum)

Maternity (Includes Private Room)

100% 100% 100%

Treatment for Congenital Defects and Pre-mature born babies

100% 100% 100%

Chemo Therapy 100% 100% 100%

(Includes chemotherapy administration, supplies and drugs used during chemotherapy procedure) Braille Machines (Up to $700 every calendar year)

100% 100% 100%

Global Emergency Assistance 100% 100% 100% Program ($500,000 calendar year maximum - Benefit includes return of mortal remains to home country)

Wellness Benefits

Routine Children Physical Exams 100% 100% 100%

Children age 0-18: 7 exams first 12 months of life; 3 exams second 12 months of life; 3 exams third 12 months of life; and 1 exam per 12 months thereafter to age 18 (includes immunizations) Routine Adult Physical Exams 100% 100% 100%

Adults age 18+ & -65: 1 exam per calendar year Adults age 65+: 1 exam per calendar year (includes immunizations)

Routine Gynecological Exams 100% 100% 100%

(Includes 1 exam and pap smear per calendar year) Mammograms 100% 100% 100%

(Unlimited visits per calendar year) Prostate Specific Antigen (PSA) 100% 100% 100%

(Includes 1 Prostate Specific Antigen Test per calendar year for males 40+)

Digital Rectal Exam (DRE) 100% 100% 100%

(Includes 1 Digital Rectal Exam per calendar year for males 40+) Cancer Screening 100% 100% 100%

(Includes 1 flex sigmoid and double barium contrast every 5 years; and at age 50+ 1 colonoscopy every 10 years)

Note: This is not evidence of coverage. You must enroll and be accepted for coverage with the Coverage Administrator before the benefits described in this document will

be effective. In case of a discrepancy between the Plan Documents, and this document, the Plan Documents will determine the Plan of Benefits. As used herein, the term

"Plan Documents" includes, but is not limited to, the Booklet, Summary of Coverage and any Booklet Amendments/Riders. For further details refer to your Plan Docu-

ments.

10/25/2011

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Effective Date: September 1, 2011

In the U.S.



Prescription Drug Coverage

Generic Drugs (365 day maximum supply)

100% 100% per one month supply (includes Mail Order Drugs)

100%

Formulary Brand Name Drugs (365 day maximum supply)

100% 100% per one month supply (includes Mail Order Drugs)

100%

Vision Expenses

Routine Eye Exam 100% 100% 100%

(Covered under medical) Includes one routine exam per calendar year

Vision Care Supplies 100% up to $400 maximum 100% up to $400 maximum 100% up to $400 maximum

(Schedule maximums apply every calendar year)

PPO Dental

In the U.S.



Individual Deductible None None None

Type A Expense (Diagnostic & Preventative)

100% 100% 100%

Type B Expense (Basic Restorative)

100% 100% 100%

Type C Expense (Major Restorative)

100% 100% 100%

Calendar Year Maximum $5,000 $5,000 $5,000

Orthodontic Treatment (Dependent Children Only)

100% 100% 100%

Orthodontia Lifetime Maximum $2,000 $2,000 $2,000

Services and Programs

Informed Health Line (24-hour nurse line) International Disease Management Interna-tional Maternity Management Program

® Simple Steps To A Healthier Life Weight Watchers® Program On-Line Global Health and Travel Information through HTH Worldwide (http//www.aetnainternational.com)

Note: This is not evidence of coverage. You must enroll and be accepted for coverage with the Coverage Administrator before the benefits described in this document

will be effective. In case of a discrepancy between the Plan Documents, and this document, the Plan Documents will determine the Plan of Benefits. As used herein, the

term "Plan Documents" includes, but is not limited to, the Booklet, Summary of Coverage and any Booklet Amendments/Riders. For further details refer to your Plan

Documents.

10/25/2011

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How to Apply for your Health Insurance ID Card Aetna International website registration and photo upload steps Downloading photos from a device to your computer There are many different ways to get photos from one device (e.g., your camera) to another (e.g., your computer). This includes, but is not limited to, a USB cord, Bluetooth connection, memory card/drive or wireless connection. The best method to transfer the photo is unique to your device.

Aetna International website registration Step 1 Type www.AetnaInternational.com in the browser URL address line. Click Go (or Enter). Click Member under Secure login.

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http://www.aetnainternational.com/�


Step 2 Click Login/Register under “Members on U.S. based plans, start here”. Step 3 Click the Register button.

Note: Once you register, you can access the site by following Steps 1 and 2 and then adding your user name and pass-word under Secure Log In.

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Step 4 Choose AGB Member from the Aetna Global Benefits Registration drop-down box. Step 5 Verify you are an active Aetna International member. If you have a plastic Aetna International member ID card with a member ID number on the front: Add the member ID number listed on the front of the card in the Member ID field (include the W). Add the following in the Temporary Password field:

The first letter of your first name PLUS the first 10 letters of your last name PLUS your date of birth in MMDDYY format

Example: John Smith born on May 6, 1967 would enter: JSMITH050667. Then select the Register button.

If you do not have a plastic Aetna International member ID card, please contact Aetna Customer Service at 1-866-236-1038 to obtain your member ID number.

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Step 6 Set up your account for future visits to the website. Choose and enter a unique user name. Your user name must: Be between six and 20 characters, and Contain no spaces. Choose and enter a unique password. Your password must: Contain at least one letter and at least one number; Be between eight and 20 characters; and Be different from your user name. (Example: 2be1validpassword) Re-enter your password in the Confirm Password field. Select a Challenge Question from the drop-down box and enter the applicable Answer. We will use this information in case you forget your password in the future. Enter a valid e-mail address. This is required to register for the website. Click the Submit button. Step 7 View the congratulations confirmation page. This will list your user name and password. Important note: Please record your user name and password in a safe place. While the challenge question can be used to assist with password recovery, user names cannot be recovered. If you forget your user name, contact the Aetna In-ternational Service Center (at the number on your member ID card) to reset your account. Log in to your Aetna International secure member website Step 1 Type www.AetnaInternational.com in the browser URL address line. Click Go (or Enter). Click Member under Secure login.

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http://www.aetnainternational.com/�


Step 2 Click Login/Register under “Members on U.S. based plans, start here”. Step 3 Add your user name and password under Secure Login and click Go.

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Upload and maintain a personal photo Step 1 Click the UPLOAD AND MAINTAIN PHOTO FOR ID CARDS link. You will then see a page listing your name and any eligible family members enrolled and approved for coverage. Step 2 Click Upload Photo for you or an individual family member. You will need to repeat the following process for each indi-vidual. Note: Family members under five years of age will not have the option to upload a photo (as this requirement does not apply to them).

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Step 3 Enter the following information on the ID Card Photo Maintenance page. Name: This is the name that will appear on the member ID card. It cannot be changed. (Note: if the total number of characters exceed 26, the ID card will list the member’s first name initial and up to 24 characters of the member’s last name.) Telephone number: Enter a 10-digit telephone number and an extension, if it applies. E-mail address: Enter a valid e-mail address. This must include a “@” and a “.” in the address. Mailing address: Add address line 1 (required). Add address line 2 (optional, use as needed). Add the 5-digit U.S. postal zip code number. This will pre-fill the city and state of your address. Confirm city and state (based on the zip code entry). Example: 123 Main Street, Apt# 14A, City, State, 55555 (zip code) Select the tip icon next to each entry field for help. Once these fields are completed: Click the Browse button. Locate and select the .jpg file to upload (for placement on the member ID card). Click the Open button, once the file name appears in the File Name field. (Or double-click on the file name when

selecting the file.)

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The path to the .jpg file will populate the area that precedes the Browse and Upload buttons.

Click the Upload button. Step 4 Adjust the uploaded photo to focus on the section that will appear on the member ID card. You can drag the small squares that border the grey frame to focus the border on your face.

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Select Save Photo and Information; Create ID Card Preview. You will then receive a confirmation page.

Step 5 On this confirmation page, you can:

Select the Review My Data and View Card Preview link to review your submitted information. Select the Print this Page link to keep a record of the successful upload. Select the Return to List of Members link to repeat this process for another covered family member (as needed).

On the Review My Data and View Card Preview link, you can:

Review the image that appears on the member ID card for: clarity (a clear photo of your entire face); format (a close, centered photo of your entire face); and appropriateness (a single image of you; no other people in the photo).

Review your phone number, e-mail and address information for accuracy. If you want to make changes to this information, select the Edit Information link to return to the ID Card Photo

Maintenance page. Select the Return to List of Members link if you are ok with the image and contact information, and wish to upload

photos for other family members.

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The Edit Information link will return you to the ID Card Photo Maintenance page where you can:

Remove the pending image and upload a new image (or re-crop the prior photo image); and/or Edit your phone number, e-mail and address information.

Once you make your changes, you can:

Click the Save Photo and Information; Create ID Card Preview link to apply any updates/changes. This will re-peat the prior process.

Click the Cancel button to cancel your updates/changes. This will prompt a “Are you sure you want to cancel and lose any changes made?” message. Click the Cancel button to return to the previous page. Click the OK button to cancel your updates/changes.

Edit or replace an existing personal photo or personal information Follow steps 1, 2 and 3 under the Log in to Aetna International’s secure member website section. Once logged in, click the UPLOAD AND MAINTAIN PHOTO FOR ID CARDS link in the middle of the page. You will then see a page listing your name and any eligible family members enrolled and approved for coverage. Click Upload Photo next to the applicable family member who needs his or her photo or information changed. The current photo and personal information will then appear on the screen.

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Click the Edit Information link to return to the ID Card Photo Maintenance page The ID Card Photo Maintenance page displays the member’s personal information. You can change the telephone num-ber, e-mail address and mailing address on this page. Any uploaded photos, not already reviewed and approved for use on the member ID card, will display as a Pending Im-age. To replace the pending image: Click the Browse button. Locate and select the .jpg file to upload (for placement on the member ID card). Click the Open button, once the file name appears in the File Name field. (Or double-click on the file name when

selecting the file.) The path to the .jpg file will populate the area that precedes the Browse and Upload buttons. Select the Upload button. The new image will then replace the previous image.

You may also click the Remove link under the image before following the above steps. Follow the remaining steps under the Upload and maintain a personal photo section. Note: If any prior approved or rejected images exist, a historical images section will show at the bottom of the page. Placing the mouse over this section will provide details on the date/time/status of each image. The color of the border or image background explains its status: grey (image pending approval or rejection), green (approved image/available for use on ID card) or red (rejected image/not available for use on ID card).

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How to Find a Health Care Provider

Visit our DocFind® online directory at www.aetna.com/docfind 1. Insert your Zip Code 2. Insert the Distance; for example: 5 or 10 miles 3. Choose the Provider Category you are looking for; for example:

Medical Providers 4. Choose the Provider Type; for example: Primary Care Physi-

cians 5- Under Plan, choose Open Choice PPO If you are looking for DENTAL, your plan will be: PPO/PDN 6. Select Start Search to get the names and addresses of the

health providers.

Primary Care Physician (PCP)

Visiting a PCP (for example, internist, pediatricians, general practitioners)

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 anytime.

Primary care doctors will guide your way

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.

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Emergency and Urgent Care Tips on Emergency Room Use

More convenient options 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 attack, stroke or unconsciousness.

If you do not have a life threatening condition, you can use one of the following options to receive high-quality care:

￭ Walk-in clinics

￭ Urgent care centers

￭ Physician’s offices

Frequently Asked Questions

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 questions. The helpful audio health library has hundreds of top-ics in both English and Spanish.

What is the number to the Informed Health Line?

1-800-556-1555

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 infections, colds, allergies, strep throat and bronchitis. An urgent care center provides care for more serious prob-lems 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 www.aetna.com/docfind.

What is the most cost effective care option?

The most cost effective option 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 location 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 condition. 1Information and Publications. Urgent Care Association of America. Accessed September 23, 2008 on www.ucaoa.org/urgentcare.html.

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http://www.aetna.com/docfind�


How to File a Claim

1. Complete the appropriate claim form, which can be found on your Aetna International secure member website at www.AetnaInternational.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. Re-ceipts must be fully itemized bills and/or detailed receipts that include diagnosis (nature of illness) and the proce-dures or services performed.

3. Write your member identification number on each document submitted 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 information (phone or fax) where you can be reached in case we have any questions about your

claim.

Completing your claim form

While it is important to fill out your claim form in its en rety, here are some fields in par c‐ular 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 reim-bursement, please make sure to fill out the claim form com-pletely and sign it. Any miss-ing informa on may result in a delay in reimbursement. Then submit it to Aetna either by fax: +1-813-775-0625 or E-mail: [email protected]

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Useful Questions and Answers

Am I covered for medical expenses anywhere in the world?

Yes. Coverage is provided to enrolled students, attending school in the U.S., and their enrolled dependents.

Does coverage terminate with Aetna International when I temporarily return to my home country for vacation?

No. Coverage stays with you anywhere in the world.

What type of customer assistance does Aetna International provide to members?

Aetna International customer service professionals are multilingual representatives with the ability to converse, compre-hend and translate virtually any language including Arabic. Our highly trained representatives are available 24 hours a day, 7 days a week at 1-866-236-1038. In addition to personalized assistance, you have access to integrated, self-service Web tools through our password-protected member website. A dedicated team of clinical case managers is also available to assist you with specialty care.

Who should I tell about changes in family status?

You should notify SACM within 30 days of any change to your family status. Changes in family status may include: marriage, divorce, or legal separation; birth or adoption; or death of a child or spouse.

What is the name of my Aetna International insurance plan?

You are enrolled in the Aetna Open Choice® PPO plan. When looking for network providers, please search for provid-ers listed under this plan name.

What is a PPO?

A PPO, or preferred provider organization, is a group of U.S.-based hospitals, doctors and other health care profession-als who have agreed to provide contracted health care services to Aetna Open Choice PPO plan participants. You are free to receive services from any health care provider you wish, but we recommend you use an Aetna PPO pro-vider to avoid any out-of-pocket costs.

When you use health care professionals (hospitals, doctors, dentists, labs, pharmacies) who belong to the Aetna PPO network, all of your medical claims will be paid at 100% with no additional 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 participating 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 International Member Services. You may also do so by calling the provider’s office. This in-cludes doctors, hospitals, labs, pharmacies, etc. What are Reasonable and Customary Guidelines? What happens if my claim exceeds the Reasonable and Cus-tomary Guidelines?

Reasonable and Customary (R&C) Guidelines are applied to claims incurred in the United States. They are geograph-ically-determined 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 entire amount over what is determined to be reasonable and customary. Claims from providers outside the United States are not subject to Reasonable and Customary guide-lines. 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: $200 Charge: $200 R&C Amount: $150 R&C Amount: $150 Aetna Reimbursement: $150 Aetna Reimbursement: $150 Student Owes: $ 0 Student Owes: $50

General Information

Insurance Terminology

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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. Information on this criteria can be found at www.Aetna.com/cpb.

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. 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 pay-ing any amounts over the Reasonable and Customary level. Regardless of network participation, 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 cesare-an section. 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 existing 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. To ensure that there is no delay of covered benefits for your child, please contact SACM within the first 30 days of your baby’s birth.

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 outpatient department, freestanding lab facility or doctor’s office. Blood work is covered whether it is for wellness or sickness. Aetna Interna-tional Member Service is available 24 hours a day, 7 days a week at 866-236-1038 to assist you with any lab or x-ray questions you may have.

Does this plan cover all dental procedures? It is strongly advised that if you are having a major dental procedure done, you ask your dentist to submit a “Pre-Determination” before the service is performed. We will review what procedures will be performed and will ad-vise you and your dentist 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.

Maternity Care

Labs and X-rays

Dental Coverage

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http://www.Aetna.com/cpb�


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 visit-ing www.aetna.com/docfind. Use the standard search function to find Aetna Vision Care® facilities 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 participation of the resident (on site) optometrist or ophthalmologist in the Aetna PPO network. Routine eye exams are covered as part of your plan of benefits. As with all doctor visits, when you schedule your appointment for a routine eye exam, please be certain that the selected provider participates 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.

Vision Benefits and Discount Program

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How to reach Aetna International Service Center is open 24 hours a day/ 7 days a week (toll-free) 1-866-236-1038 (Inside the USA) 1-813-775-0190 (Outside the USA) Fax 1-800-475-8751 (Inside the USA) 1-813-775-0625 (Outside the USA) Mailing Address El Paso, Texas 79998-3836 P.O. Box 981543 USA Urgent Mail

Aetna International 4630 Woodland Corporation BLVD Tampa, FL 33614 USA Website www.AetnaInternational.com General Questions [email protected]

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Health insurance plans and programs are offered, underwritten or administered by Aetna Life & Casualty (Bermuda) Ltd. or Aetna Life Insurance Company (Aetna). Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. Information subject to change. For more infor-mation about Aetna International, refer to www.AetnaInternational.com.

We can assist you with: Locating quality health care

in the USA Answering questions re-

garding claims, benefit lev-els and coverage

Processing claims in virtu-ally any language

Coordinating reimburse-ment in over 180 currencies and payments through elec-tronic reimbursement di-rectly to bank accounts

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