By your side
Aetna® Critical Illness Plan
Be prepared for what happens next
Critical illness coverage can keep you focused on your health when it matters most. These plans can help ease some financial worries during a difficult time.
An Aetna Critical Illness Plan can help
The Aetna Critical Illness Plan pays you lump-sum cash benefits when a doctor diagnoses you with a covered serious illness or condition, like heart attack, stroke, cancer and more.* You can use the money to help pay out-of-pocket medical costs or personal expenses.
How is this different from a major medical plan?
Medical plans help pay providers for services and treatment. But, they don’t cover the unexpected costs that can come with a serious illness.
The Aetna Critical Illness Plan pays benefits directly to you, giving you extra cash when you need it most. It can help fill in the gaps, making it a great companion to your major medical plan.
How can you use the cash benefits?
It’s completely up to you. You can use the money any way you want, like:
Deductibles or copays
Mortgage or rent
Groceries or utility bills
...or for anything else you choose.
Easy to use
You can file a claim in about 90 seconds or less if you or a family member experience a covered diagnosis or condition. And, benefits get paid directly to you by check or direct deposit.
*Refer to your plan documents to see all covered illnesses under the plan.
Aetna Critical Illness
Did you know?
More than 1 in 3 Americans have heart disease, making it the most expensive health condition in the U.S. at a combined $555 billion 1
Having less to worry about
Dan* knows that heart disease runs in his family. And when a heart attack struck, he was thankful he had the Aetna Critical Illness plan.
He filed his claim easily online and benefits were deposited directly into his bank account. As an Aetna medical member, he didn’t need to upload any medical bills.
He was able to use the money to help pay his out-of-pocket medical costs and other bills such as his children’s daycare tuition.
A Simplified Claims Experience™
Just register on the My Aetna Supplemental app or on the member portal at MyAetnaSupplemental.com to view plan documents, submit and track claims, and sign up for direct deposit. Aetna Medical members can also visit Aetna.com to access the member portal
Filing a claim is easy! Click “Report New Claim” and answer a few quick questions. Filing claims is even easier for Aetna Medical Plan members. Aetna Easy File™ uses information from your medical claim to process your critical illness plan claim. That’s less paperwork for you. Don’t have Aetna Medical? No problem- just upload or take a picture of your medical bill.
You can also print and mail a paper claim form to Aetna Voluntary Plans.
1WebMD. Top 11 Medical Expenses. November, 2021. Available at: https://www.webmd.com/healthy-aging/ss/slideshow-top-11-medical-expenses. Accessed June 3, 2022.
*This is a fictional example of how the plan could work.
THIS PLAN DOES NOT COUNT AS MINIMUM ESSENTIAL
COVERAGE UNDER THE AFFORDABLE CARE ACT. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE.
This insurance plan provides limited benefits. It pays fixed dollar benefits for covered services without regard to the health care provider’s actual charges. The benefits payments are not intended to cover the full cost of medical care. You are responsible for making sure the provider’s bills get paid. These benefits are paid in addition to any other health coverage you may have. This material is for information only. Insurance plans contain exclusions and limitations. Not all health services are covered, and coverage is subject to applicable laws and regulations, including economic and trade sanctions. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features, rates, eligibility and availability may vary by location and are subject to change. For more information about Aetna plans, refer to Aetna.com.
Policy forms issued in Oklahoma include: GR-96843, AL HCOC-VOL CI 01, AL HPOL-VOL CI 01.
Policy forms issued in Missouri include: GR-96844 01, AL HCOC-VOL CI 01, AL HPOL-VOL CI 01.
BENEFIT SUMMARY
City of Haltom City
803272
Aetna Critical Illness Basic
THIS IS NOT A MEDICARE SUPPLEMENT (MEDIGAP) PLAN. If you are or will become eligible for Medicare, review the free Guide to Health Insurance for People with Medicare available at www.medicare.gov.
Insurance plans are underwritten by Aetna Life Insurance Company. The benefits in the table below will be paid when you are diagnosed with a covered Critical Illness. Unless otherwise indicated, all benefits and limitations are per covered person.
Critical Illness Benefits – Childhood Condition
Covered
Cerebral palsy
Pays a benefit when you are diagnosed with Cerebral palsy by a physician. Other similar conditions that can be outgrown, are not included in this definition.
Cleft lip or cleft palate
Pays a benefit when you are diagnosed with a Cleft Lip or Cleft Palate after live birth by a physician.
Congenital heart defect
Pays a benefit when you are diagnosed with Congenital heart defect by a physician.
Cystic fibrosis
Pays a benefit when you are diagnosed with Cystic fibrosis by a physician. The diagnosis must be confirmed with sweat chloride concentrations greater than 60 mmol/L.
Down syndrome
Pays a benefit when you are diagnosed with Down Syndrome, the first date after live birth and based on the physician's study of the 21st chromosome revealing trisomy 21, translocation, or mosaicism.
Sickle cell anemia
Pays a benefit when you are diagnosed with Sickle cell anemia by a physician.
Spina bifida
Pays a benefit when you are diagnosed with Spina bifida by a specialist physician and must be associated with neurologic symptoms including motor impairment. Spina bifida does not include spina bifida occulta.
Critical Illness Benefits - Chronic Condition
Primary sclerosing cholangitis (PSC)
Pays a benefit when you are diagnosed with Primary sclerosing cholangitis (PSC), also known as "Walter Payton's disease" by a physician.
Critical Illness Benefits - Infectious Disease
Covered Benefit
Cholera
Pays a benefit when you are diagnosed with Cholera by a physician.
Coronavirus
"Pays a benefit when you are diagnosed with Coronavirus. Coronaviruses (CoV) are a large family of viruses that cause illness in people such as:
• CoV or SARS-CoV-1 is the coronavirus that causes severe acute respiratory syndrome (SARS).
• SARS-CoV-2 is the coronavirus that causes COVID-19.
• MERS-CoV is the coronavirus that causes Middle East Respiratory Syndrome (MERS).
MIS-C and MIS-A are associated with the COVID-19 coronavirus strain. You must have a stay in a hospital, rehabilitation unit, or skilled nursing facility for at least 5 consecutive days."
Creutzfeldt-Jakob disease
Pays a benefit when you are diagnosed with Creutzfeldt-Jakob disease (CJD). You must have a stay in a hospital, rehabilitation unit, or skilled nursing facility for at least 5 consecutive days.
Diphtheria
Pays a benefit when you are diagnosed with Diphtheria by a physician.
Ebola
Pays a benefit when you are diagnosed with Ebola. You must have a stay in a hospital, rehabilitation unit, or skilled nursing facility for at least 5 consecutive days.
Encephalitis
Pays a benefit when you are diagnosed with Encephalitis by a physician. Encephalitis does not include encephalitis resulting from any human immuno-deficiency virus (HIV) infection or other ancillary infections resulting from the HIV infection.
Hepatitis - occupational
Pays a benefit when you are diagnosed with Occupational hepatitis B, C, or D resulting from accidental exposure by contaminated body fluids.
Human immunodeficiency virus (HIV)
Pays a benefit when you are diagnosed with Human immunodeficiency virus (HIV). HIV means the presence of HIV or antibodies to the HIV virus which is caused by an accidental needle stick or sharp injury or by mucous membrane exposure to blood or bloodstained bodily fluid.
Legionnaire's disease
Pays a benefit when you are diagnosed with Legionnaire's disease by a physician.
Lyme disease
Pays a benefit when you are diagnosed with Lyme Disease by a physician.
Malaria
Pays a benefit when you are diagnosed with Malaria by a physician.
Meningitis - Bacterial , Viral , Fungal , Parasitic , Amebic
Pays a benefit when you are diagnosed with Bacterial meningitis by a physician.
Covered Benefit
Methicillin-resistant staphylococcus aureus (MRSA)
Pays a benefit when you are diagnosed with Methicillin-resistant staphylococcus aureus (MRSA) by a physician.
Necrotizing fasciitis
Pays a benefit when you are diagnosed with Necrotizing fasciitis, commonly known as flesh-eating disease or flesh-eating bacteria syndrome, and requiring a surgical procedure to be performed by a physician.
Osteomyelitis
Pays a benefit when you are diagnosed with Osteomyelitis by a physician.
Pneumonia - Bacterial , Viral
Pays a benefit if you are diagnosed with bacterial or viral pneumonia. You must have a stay in a hospital, rehabilitation unit, or skilled nursing facility for at least 5 consecutive days.
Poliomyelitis
Pays a benefit when you are diagnosed with Poliomyelitis resulting from poliovirus type 1, 2, or 3 that is characterized by fever, paralysis and atrophy of skeletal muscles by a physician.
Rabies
Pays a benefit when you are diagnosed with Rabies by a physician.
Rocky mountain spotted fever (RMSF)
Pays a benefit when you are diagnosed with Rocky mountain spotted fever (RMSF) by a physician.
Septic shock including severe sepsis
Pays a benefit if you are diagnosed with septic shock and sepsis. You must have a stay in a hospital, rehabilitation unit, or skilled nursing facility for at least 5 consecutive days
Tetanus
Pays a benefit when you are diagnosed with Tetanus by a physician.
Tuberculosis (TB)
Pays a benefit when you are diagnosed with Tuberculosis (TB) by a physician.
Tularemia
Pays a benefit when diagnosed with Tularemia (sometimes called rabbit fever) by a physician.
Typhoid Fever
Pays a benefit when you are diagnosed with Typhoid fever by a physician.
Variant influenza virus (swine flu in humans)
Pays a benefit when you are diagnosed with Variant influenza virus by a physician.
Maximum infectious disease diagnosis per plan year 1
Note: the following infectious disease benefits require a hospital stay of at least 5 days: Coronavirus, Creutzfeldt-Jakob disease, Ebola, Pneumonia, Septic shock and severe sepsis, Variant influenza virus (swine flu in humans)
Critical Illness Benefits – Neurological (Brain)
Covered Benefit
Amyotrophic lateral sclerosis (ALS)
Pays a benefit when you are diagnosed with Advanced amyotrophic lateral sclerosis (ALS), also known as "Lou Gehrig's disease" by a physician. ALS does not include other motor neuron diseases. This disease is characterized by the progressive degeneration of motor neurons, shown by permanent neurological defect with persisting clinical signs and symptoms such as the inability to perform 3 or more activities of daily living, and or the need for either a feeding tube or non-invasive ventilation.
Alzheimer's disease
Pays a benefit when you are diagnosed with Alzheimer's disease, diagnosis of the disease by a psychiatrist or neurologist. You must have the inability to independently perform 3 or more of the activities of daily living.
Benign brain tumor including spinal cord tumor
Pays a benefit when you are diagnosed with a Benign brain tumor by a physician.
Coma (non-induced)
Pays a benefit when you are diagnosed with Coma, characterized by the absence of eye opening, verbal response and motor response, and the individual requires intubation for respiratory assistance (a medically induced coma is not covered). The Coma must last for a period of 14 or more consecutive days.
Parkinson's disease
Pays a benefit when you are diagnosed with Parkinson's disease by a psychiatrist or neurologist.
Persistent vegetative state (PVS)
Pays a benefit when diagnosed with Persistent vegetative state (PVS) by a physician.
Stroke
Pays a benefit when you are diagnosed with a Stroke resulting in paralysis or other measurable objective neurological defect persisting for more than 24 hours.
Transient ischemic attack (TIA)
Pays a benefit when you are diagnosed with Transient ischemic attack (TIA) by a physician. TIA does not include a stroke.
Maximum per lifetime 1
Critical Illness Benefits – Other
Covered Benefit
End-stage renal or kidney failure
Pays a benefit when you are diagnosed with End stage renal or kidney failure, and the insured person has to undergo regular hemodialysis or peritoneal dialysis at least weekly or your physician determines that complete replacement of the entire organ is necessary, and you are placed on a national transplant list, such as UNOS (United Network for Organ Sharing).
Loss of hearing
Pays a benefit when you are diagnosed with Loss of hearing in both ears that cannot be corrected to any functional degree by any procedure, aid or device. Loss of hearing has to continue for a period of 90 consecutive days.
Loss of sight (blindness)
Pays a benefit when you are diagnosed with Loss of sight (blindness) that is total and irrecoverable loss of sight in both eyes. Loss of sight (blindness), has to continue for a period of 90 consecutive days.
Loss of speech
Pays a benefit when you are diagnosed with Loss of speech that cannot be corrected to any functional degree by any procedure, aid or device. Loss of speech has to continue for a period of 90 consecutive days.
Major organ failure
Pays a benefit when you are diagnosed with a Major organ failure of the heart, liver, lung(s), or pancreas resulting in the insured person being placed on the UNOS (United Network for Organ Sharing) list for a transplant.
Paralysis
Pays a benefit when you are diagnosed with any of the types of paralysis below, and your physician confirms the paralysis continued for a period of 60 consecutive days.
Third-degree burns
Pays a benefit when you are diagnosed with a Third degree burn that covers more than 10% of total body surface (also called full-thickness burn).
Critical Illness Benefits – Vascular (Heart)
Coronary artery condition requiring bypass surgery
Pays a benefit when you are diagnosed with a Coronary artery condition in which the patient is placed on a cardiac pulmonary bypass machine and a bypass graft is performed.
Heart attack (myocardial infarction)
Pays a benefit when you are diagnosed with a Heart attack (Myocardial Infarction) resulting from a blockage of one or more coronary arteries.
Sudden cardiac arrest
Pays a benefit when you are diagnosed with Sudden cardiac arrest by a physician. Sudden cardiac arrest does not include heart attack. The sudden cardiac arrest benefit is not payable if the sudden cardiac arrest is caused by, or contributed to by, a heart attack.
Critical Illness Benefit Features
Subsequent critical illness diagnosis
Subsequent diagnosis of a different covered Critical Illness is payable at the original amount if it occurs after the previous date of diagnosis for which a benefit was paid.
Recurrence critical illness diagnosis
If an insured person has been initially diagnosed with and received a benefit under this plan for a critical illness and then is diagnosed with the same critical illness again at the number of days specified in the minimum below or later, we will pay the stated percentage of the benefit as shown in the Schedule of Benefits for the recurring critical illness diagnosed.
Minimum days between diagnosis of same condition
No benefit payable if the recurrence occurs within a timeframe that is less than the number of days specified 180 days
Cancer Benefits
Covered Benefit
Cancer (invasive)
Pays a benefit when you are diagnosed with Cancer (invasive) that is identified by the presence of malignant cells or a malignant tumor characterized by the uncontrolled and abnormal growth and spread of invasive malignant cells.
Carcinoma in situ (non-invasive)
Pays a benefit when you are diagnosed with Carcinoma in situ that is in the natural or normal place, confined to the site of origin without having invaded neighboring tissue. Skin cancer will not be considered carcinoma in situ for purposes of this Certificate.
Skin cancer
Pays a benefit when you are diagnosed with Skin Cancer (melanoma of Clark's Level I or II Breslow less than .75mm); basal cell carcinoma; or squamous cell carcinoma of the skin. Skin cancer benefit provides coverage for invasive malignant melanoma in the dermis or deeper or skin malignancies that have become metastatic.
$1,000
Maximum per lifetime 1
Recurrence cancer (invasive) diagnosis
If an insured person has been initially diagnosed with and received a benefit for cancer (invasive) under this plan and is then diagnosed with any kind of cancer (invasive) again at the number of days specified in the minimum below or later, we will pay the stated percentage of the Cancer Benefit for Cancer (invasive) as shown on the Schedule of Benefits for the cancer (invasive) diagnosed.
Minimum days between diagnosis of cancer (invasive)**
No benefit payable if the recurrence occurs within a time frame less than the number of days specified 180 days
Recurrence carcinoma in situ diagnosis
If an insured person has been initially diagnosed with and received a benefit for carcinoma in situ (non-invasive) under this plan and is then diagnosed with any kind of carcinoma in situ (non-invasive) again at the number of days specified in the minimum below or later, we will pay the stated percentage of the carcinoma in situ (non-invasive) as shown on the Schedule of Benefits for the carcinoma in situ (non-invasive) diagnosed.
Minimum days between diagnosis of carcinoma in situ**
No benefit payable if the recurrence occurs within a time frame less than the number of days specified 180 days
* For those members who were diagnosed with cancer prior to their effective date of coverage under the Aetna plan and then receive another cancer diagnosis (the first time) while covered under the Aetna plan, we will treat their diagnosis as an ‘initial’ diagnosis under the Aetna plan.
** In addition to the separation period, the insured person must be treatment free during the separation period. Treatment does not include maintenance drug therapy or routine follow-up visits to a physician to confirm the initial cancer or carcinoma in situ has not returned
Health Screening Rider
Covered Benefit Benefit Amount
Health screening $50
Pays once per member per plan year for covered preventive tests.
Maximum per plan year 1
Covered Health Screenings
• Bone marrow screening
• Bone mass density measurement (DEXA, DXA)
• Biopsies for cancer
• Blood chemistry panel
• Breast sonogram
• Breast MRI
• Breast ultrasound
• Cancer antigen 125 blood test for ovarian cancer (CA 125)
• Carotid doppler ultrasound
• Chest x-ray (CXR)
• Cytologic screening
• Cancer antigen 15-3 blood test for breast cancer (CA 15-3)
• Carcinoembryonic antigen blood test for colon cancer (CEA)
• Clinical testicular exam
• Colonoscopy
• Complete blood count (CBC)
• Dental exam
• Digital rectal exam (DRE)
• Doppler screening for cancer
• Doppler screenings for peripheral vascular disease (also known as arteriosclerosis)
• Electroencephalogram (EEG)
• Electrocardiogram (EKG, ECG)
• Echocardiogram (ECHO)
• Endoscopy
• Eye exam
• Fasting blood glucose test
• Fasting plasma glucose test
• Flexible sigmoidoscopy
• Hearing test
• Hemoccult stool analysis
• Hemoglobin A1C
• Human papillomavirus vaccination (HPV)
• Infectious disease testing
• Immunizations
• Lipoprotein profile (serum plus HDL, LDL, total cholesterol, and triglycerides)
• Mammography
• Oral cancer screening
• Pap smear
• Prostate specific antigen (PSA) test
• Routine health check-up exam
• Skin cancer biopsy
• Skin cancer screening
• Skin exam
• Serum protein electrophoresis (blood test for myeloma)
• Successful completion of smoking cessation program
• Stress test on bicycle or treadmill
• Test for sexually transmitted infections (STIs)
• Thermography
• ThinPrep pap test
• Two-hour post-load plasma glucose test
• Ultrasound for cancer detection
• Ultrasound screening for abdominal aortic aneurysms
• Virtual colonoscopy
Note: COVID-19 testing is covered as an eligible health screening benefit
Waiver of Premium
Covered Benefit Benefit Amount
If, as a result of your covered critical illness you miss 30 continuous days of work we will waive the premium beginning on the first premium due date that occurs after the 30th day of your absence, through the next 6 months of coverage. During such absence, you must remain employed with the policyholder. The premium waiver does not apply to your covered dependents. Included
Critical Illness Plan Exclusions and Limitations
This plan has exclusions and limitations. Refer to the actual booklet certificate and schedule of benefits to determine which services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, the plan may contain exceptions to this list based on state mandates or the plan design purchased.
Benefits under the policy will not be payable for a diagnosis related to the following:
1. Act of war, riot, war;
2. Care provided by immediate family members or any household member;
3. Suicide or attempt at suicide, intentionally self-inflicted injury, or any attempt at self-inflicted injury, or any form of intentional asphyxiation, except when resulting from a diagnosed disorder;
4. Being under the influence of a stimulant (such as amphetamines), depressant, hallucinogen, narcotic or any other drug intoxicant, including those prescribed by a physician that are misused by the covered person, except when resulting from a diagnosed disorder;
The critical illness date of diagnosis must be on or after the effective date of the certificate and while coverage is in force. The diagnosis must be given or received in the United States or its territories.
Portability
Your plan includes a portability option which allows you to keep your existing coverage by making direct payments to the carrier. You may exercise this option, if your employment ceases for any reason. Refer to your Certificate for additional portability provisions.
Questions and Answers about the Critical Illness Plan
How do I know if I’m considered a tobacco user and should select the tobacco rates?
You are a Tobacco User if you currently use or have used any tobacco products in the past 12 months. Tobacco products include, but are not limited to, cigarettes, cigars, snuff, dip, chew, pipe and/or any nicotine delivery system.
Can I have more than one Critical Illness Plan?
No, you are not allowed to have more than one Aetna Critical Illness Plan.
What does Face Amount mean?
The face amount is the maximum benefit a plan pays for a covered diagnosis for a member. Your benefits are based on a percentage of the face amount, or a specific dollar amount, as shown. Your dependents’ benefits are based on a percentage of your benefits
To whom are benefits paid?
Benefits are paid to you, the member.
Is my Aetna Critical Illness policy compatible with a Health Savings Account (HSA)?
Yes, Aetna Critical Illness policies are compatible with Health Savings Accounts.
How do I submit a claim?
Go to myaetnasupplemental.com and either “Log In” or “Register”, depending on if you’ve set up your account. Click the “Create a new claim” button and answer a few quick questions. You can even save your claim to finish later. You can also print/mail in form(s) to: Aetna Voluntary Plans, PO Box 14079, Lexington, KY 40512-4079, or you can ask us to mail you a printed form.
What if I don’t understand something I’ve read here, or have more questions?
Please call us. We want you to understand these benefits before you decide to enroll. You may reach one of our Customer Service representatives Monday through Friday, 8 a.m. to 6 p.m., by calling 1-800-607-3366. We’re here to answer questions before and after you enroll.
What should I do in case of an emergency?
In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility.
What happens if I lose my employment, can I take the Critical Illness Plan with me?
Should you lose your job, you are able to continue coverage under the Portability provision. You will need to pay premiums directly to Aetna.
THESE PLANS DO NOT COUNT AS MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT. THESE PLANS ARE A SUPPLEMENT
TO HEALTH INSURANCE
AND ARE NOT
A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE.
These plans provide limited benefits. They pay fixed dollar benefits for covered services without regard to the health care provider's actual charges. These benefit payments are not intended to cover the full cost of medical care. You are responsible for making sure the provider's bills get paid. These benefits are paid in addition to any other health coverage you may have.
In order for benefits to be payable, the date of diagnosis must occur while coverage for the insured person is in force; you must be diagnosed while your coverage is in effect.
Please review your Cancer buyer’s guides: http://demo.avpenroll.com/media/1591/maine- nh-prod_serv_consumer_guide_cancer.pdf http://demo.avpenroll.com/media/1590/aetna-utah_ci_buyersguide.pdf
Complaints and appeals
Please tell us if you are not satisfied with a response you received from us or with how we do business. Call Member Services to file a verbal complaint or to ask for the address to mail a written complaint. You can also e-mail Member Services through the secure member website. If you’re not satisfied after talking to a Member Services representative, you can ask us to send your issue to the appropriate department.
If you don’t agree with a denied claim, you can file an appeal. To file an appeal, follow the directions in the letter or explanation of benefits statement that explains that your claim was denied. The letter also tells you what we need from you and how soon we will respond.
We protect your privacy
We consider personal information to be private. Our policies protect your personal information from unlawful use. By “personal information,” we mean information that can identify you as a person, as well as your financial and health information. Personal information does not include what is available to the public. For example, anyone can access information about what the plan covers. It also does not include reports that do not identify you.
When necessary for your care or treatment, the operation of our health plans or other related activities, we use personal information within our company, share it with our affiliates and may disclose it to: your doctors, dentists, pharmacies, hospitals and other caregivers, other insurers, vendors, government departments and third-party administrators (TPAs). We obtain information from many different sources particularly you, your employer or benefits plan sponsor if applicable, other insurers, health maintenance organizations or TPAs, and health care providers.
These parties are required to keep your information private as required by law. Some of the ways in which we may use your information include: Paying claims, making decisions about what the plan covers, coordination of payments with other insurers, quality assessment, activities to improve our plans and audits.
We consider these activities key for the operation of our plans. When allowed by law, we use and disclose your personal information in the ways explained above without your permission. Our privacy notice includes a complete explanation of the ways we use and disclose your information. It also explains when we need your permission to use or disclose your information.
We are required to give you access to your information. If you think there is something wrong or missing in your personal information, you can ask that it be changed. We must complete your request within a reasonable amount of time. If we don’t agree with the change, you can file an appeal.
If you’d like a copy of our privacy notice, call 1-800-607-3366 or visit us at www.aetna.com.
If you require language assistance, please call Member Services at 1-800-607-3366 and an Aetna representative will connect you with an interpreter. If you’re deaf or hard of hearing, use your TTY and dial 711 for the Telecommunications Relay Service. Once connected, please enter or provide the Aetna telephone number you’re calling.
Si usted necesita asistencia lingüística, por favor llame al Servicios al Miembro a 1-800-607-3366, y un representante de Aetna le conectará con un intérprete. Si usted es sordo o tiene problemas de audición, use su TTY y marcar 711 para el Servicio de Retransmisión de Telecomunicaciones (TRS). Una vez conectado, por favor entrar o proporcionar el número de teléfono de Aetna que está llamando.
ATTENTION MASSACHUSETTS RESIDENTS: As of January 1, 2009, the Massachusetts Health Care Reform Law requires that Massachusetts residents, eighteen (18) years of age and older, must have health coverage that meets the Minimum Creditable Coverage standards set by the Commonwealth Health Insurance Connector, unless waived from the health insurance requirement based on affordability or individual hardship. For more information call the Connector at 1-877-MA-ENROLL (1-877-623-6765) or visit the Connector website (www.mahealthconnector.org). THIS POLICY, ALONE, DOES NOT MEET MINIMUM CREDITABLE COVERAGE STANDARDS. If you have questions about this notice, you may contact the Division of Insurance by calling 1-617-521-7794 or visiting its website at www.mass.gov/doi.
Plans are underwritten by Aetna Life Insurance Company (Aetna). This material is for information only and is not an offer or invitation to contract. Each insurer has sole financial responsibility for its own products.
Providers are independent contractors and are not agents of Aetna. Aetna does not provide care or guarantee access to health services. Insurance plans contain exclusions and limitations. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Policies may not be available in all states, and rates and benefits may vary by location. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com.
Financial Sanctions Exclusions Clause
If coverage provided by this policy violates or will violate any US economic or trade sanctions, the coverage is immediately considered invalid. For example, Aetna companies cannot make payments or reimburse for health care or other claims or services if it violates a financial sanction regulation. This includes sanctions related to a blocked person or entity, or a country under sanction by the United States, unless permitted under a valid written Office of Foreign Assets Control (OFAC) license. For more information on OFAC, visit the website below: http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx
Policy forms issued in Idaho, Oklahoma and Missouri include: GR-96843, GR- 96844.
DiscriminationisAgainsttheLaw
AetnaInc.complieswithapplicableFederalcivilrightslawsanddoesnotdiscriminateonthebasis ofrace,color,nationalorigin,age,disability,orsex(consistentwith45CFR§92.101(a)(2)).Aetna Inc.doesnotexcludepeopleortreatthemlessfavorablybecauseofrace,color,nationalorigin, age,disability,orsex.
AetnaInc.:
• Providespeoplewithdisabilitiesreasonablemodificationsandfreeappropriateauxiliary aidsandservicestocommunicateeffectivelywithus,suchas:
o Qualifiedsignlanguageinterpreters
o Writteninformationinotherformats(largeprint,audio,accessibleelectronic formats,otherformats).
• Providesfreelanguageassistanceservicestopeoplewhoseprimarylanguageisnot English,whichmayinclude:
o Qualifiedinterpreters
o Informationwritteninotherlanguages.
Ifyouneedreasonablemodifications,appropriateauxiliaryaidsandservices,orlanguageassistance services,call1-800-872-3862(TTY:711)orthenumberonthebackofyourIDcard.
IfyoubelievethatAetnaInc.hasfailedtoprovidetheseservicesordiscriminatedinanotherwayon thebasisofrace,color,nationalorigin,age,disability,orsex,youcanfileagrievancewith:
CivilRightsCoordinator
Attn:1557Coordinator
CVSPharmacy,Inc.
1CVSDrive,MC2332, Woonsocket,RI02895
Phone:1-800-648-7817,TTY:711
Email:CRCoordinator@aetna.com
Youcanfileagrievanceinperson,bymail,oremail.Ifyouneedhelpfilingagrievance,theCivil RightsCoordinatorisavailabletohelpyou.
YoucanalsofileacivilrightscomplaintwiththeU.S.DepartmentofHealthandHumanServices, OfficeforCivilRights,electronicallythroughtheOfficeforCivilRightsComplaintPortal,availableat https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,orbymailorphoneat:
U.S.DepartmentofHealthandHumanServices
200IndependenceAvenue,SW Room509F,HHHBuilding Washington,D.C.20201 1-800-368-1019,1-800-537-7697(TDD)
Complaintformsareavailableathttp://www.hhs.gov/ocr/office/file/index.html. ThisnoticeisavailableatAetnaInc.’swebsite:https://www.aetna.com/
5356157-01-01(07/25)
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Cushitic-Oromo Tajaajila afaanii bilisaan argachuuf, irratti bilbilaa.
French Afin d'accéder aux services langagiers sans frais, composez le .
French Creole (Haitian) Pou w jwenn aksè ak sèvis lang gratis pou ou, rele .
German Um kostenlos auf Sprachdienste zuzugreifen, rufen Sie an.
Greek Για
Gujarati
Hindi
Hmong Xav tau kev pab txhais lus tsis muaj nqi them rau koj, hu .
Italian Per accedere ai servizi linguistici, senza alcun costo per lei, chiami il numero . Japanese 無料の言語サービスをご利用いただくには、 にお電話ください。
Karen လၢကမၤန့ၢ်
Korean
Laotian
.
Mon-Khmer, Cambodian េដម្បទទលេនសវាាែផនកភាាសាាេដាាយមនគៃតថលពអនកសមទរសពទេទលខ ។
Navajo T’áá ni nizaad k’ehjí bee níká a’doowoł doo bą́ą́h ílínígóó kojį’ hólne’ .
Pennsylvanian-Dutch Um Schprooch Services zu griege mitaus Koscht, ruff .
Persian-Farsi
Polish Aby uzyskać bezpłatny dostęp do usług językowych, zadzwoń pod numer .
Portuguese Ligue para para receber assistência linguística gratuita.
Punjabi
Russian
Samoan Mo le mauaina o auaunaga tau gagana e aunoa ma se totogi, vala’au le .
Serbo-Croatian Za besplatne prevodilačke usluge pozovite .
Spanish Para acceder a los servicios de idiomas sin costo, llame al
Syriac-Assyrian
Tagalog Upang ma-access ang mga serbisyo sa wika nang wala kang babayaran, tumawag sa
Thai