Aetna HealthFund® HDHP with HSA - AetnaFeds.com

HDHP: 22 Coverage Period: 01/01/2013 – 12/31/2013
Summary of Benefits and Coverage
Coverage for: Self -or- Self and Family | Plan Type: PPO
Common
Medical Event
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
If you need help
recovering or have
other special health
needs
If your child needs
dental or eye care
Services You May Need
Your Cost If You
Use a Preferred
Provider
Questions: Call 1-888-238-6240 or visit us at www.AetnaFeds.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.AetnaFeds.com or call 1-888-238-6240 to request a copy.
Your Cost If You Use a
Non- Participating
Provider
(plus you may be
balance billed)
Limitations & Exceptions
Mental/Behavioral health
outpatient services
10% coinsurance 30% coinsurance ––––––––––– None –––––––––––
Mental/Behavioral health inpatient
Inpatient services require precertification
10% coinsurance 30% coinsurance
services
or a penalty may apply.
Substance use disorder outpatient
services
10% coinsurance 30% coinsurance ––––––––––– None –––––––––––
Substance use disorder inpatient
Inpatient services require precertification
10% coinsurance 30% coinsurance
services
or a penalty may apply.
No Charge for
Subsequent postnatal visits 10% for
Prenatal and postnatal care prenatal and first 30% coinsurance
Preferred provider and 30% for nonparticipating
postnatal care visit
provider
Delivery and all inpatient services 10% coinsurance 30% coinsurance ––––––––––– None –––––––––––
Limited to 3 visits per day with each visit
Home health care 10% coinsurance 30% coinsurance
equal to a period of 4 hours or less.
Precertification is required.
Coverage limited to 60 consecutive days
Rehabilitation services 10% coinsurance 30% coinsurance
per condition, per member, per calendar
year for speech, physical and occupational
therapy.
Habilitation services Not covered Not covered Not covered
Inpatient services require precertification
Skilled nursing care 10% coinsurance 30% coinsurance
or a penalty may apply. 60 days per
calendar year maximum.
Durable medical equipment 10% coinsurance 30% coinsurance ––––––––––– None –––––––––––
Hospice service 10% coinsurance 30% coinsurance
Inpatient services require precertification
or a penalty may apply.
Eye exam No charge 30% coinsurance 1 exam every 12 months maximum.
Glasses Covered Covered
Reimbursement up to $100 every 24
months maximum.
Dental check-up No charge Not covered ––––––––––– None –––––––––––
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