Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover
(This isn't a complete list. Check your policy or plan document for other
excluded services
.)
•
•
•
•
•
• Routine foot care
•
Other Covered Services
(This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)
•
•
•
•
•
•
•
To see examples of how this plan might cover costs for a sample medical situation, see the next page.
Your Grievance and Appeals Rights:
Glasses
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum
essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does
meet the minimum value standard for the benefits it provides.
Dental Care
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any
such rights may be limited in duration and will require you to pay a
premium
, which may be significantly higher than the
premium
you pay while covered under the plan.
Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-800-558-0860. You may also contact your state insurance department, the U.S. Department
of Labor, Employee Benefits Security Administration at 1-866-444-3272 o
or the U.S. Department of Health and Human Services at 1-877-267-2323
x61565 o
Weight loss programs (prescription drugs only)
Acupuncture (covered in lieu of anesthesia only)
Hearing aids - No charge up to $400 maximum per
ear every 36 months. Deductible and coinsurance
waived.
Routine eye care (one routine eye exam per
calendar year)
Language Access Services:
Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-558-0860.
Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-558-0860.
如果需要中文的帮助，
请拨打这个号码
1-800-558-0860.
Para obtener asistencia en Español, llame al 1-800-558-0860.
Non-emergency care when traveling outside the
U.S.
Long-term care
Chiropractic care (limited to 26 visits per year)
Infertility treatment (limitations and exclusions
apply; please see plan documents or call
Aetna
One
Premier at 1-800-558-0860).
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to
appeal
or file a
grievance
. For questions about your
rights, this notice, or assistance, you can contact: Aetna at 1-800-558-0860 or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA
(3272) o
Private duty nursing (inpatient)
Bariatric surgery (covered at an Institute of Quality facility
only)
Cosmetic surgery
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