George Mason University - Aetna Student Health

Termination and RefundsWithdrawal from Classes – Leave of AbsenceIf you withdraw from classes under a school-approved leave of absence, your coverage will remain in force throughthe end of the period for which payment has been received and no premiums will be refunded.Withdrawal from Classes – Other than Leave of AbsenceIf you withdraw from classes other than under a school-approved leave of absence within 31 days after the policyeffective date, you will be considered ineligible for coverage, your coverage will be terminated retroactively and anypremiums collected will be refunded. If the withdrawal is more than 31 days after the policy effective date, yourcoverage will remain in force through the end of the period for which payment has been received and no premiumswill be refunded. If you withdraw from classes to enter the armed forces of any country, coverage will terminate asof the effective date of such entry and a pro rata refund of premiums will be made if you submit a written requestwithin 90 days of withdrawal from classes.In-network Provider NetworkAetna Student Health offers Aetna’s broad network of In-network Providers. You can save money by seeing Innetwork Providers because Aetna has negotiated special rates with them, and because the Plan’s benefits arebetter.If you need care that is covered under the Plan but not available from an In-network Provider, contact MemberServices for assistance at the toll-free number on the back of your ID card. In this situation, Aetna may issue a preapproval for you to receive the care from an Out-of-network Provider. When a pre-approval is issued by Aetna, thebenefit level is the same as for In-network Providers.PrecertificationYou need pre-approval from us for some eligible health services. Pre-approval is also called precertification. Your innetwork physician is responsible for obtaining any necessary precertification before you get the care. When you goto an out-of-network provider, it is your responsibility to obtain precertification from us for any services andsupplies on the precertification list. If you do not precertify when required, there is a 500 penalty for each type ofeligible health service that was not precertified. For a current listing of the health services or prescription drugs thatrequire precertification, contact Member Services or go to www.aetna.com.Precertification CallPrecertification should be secured within the timeframes specified below. To obtain precertification, call MemberServices at the toll-free number on your ID card. This call must be made:Non-emergency admissions:You, your physician or the facility will need to call and requestprecertification at least 14 days before the date you are scheduled to beadmitted.An emergency admission:You, your physician or the facility must call within 48 hours or as soon asreasonably possible after you have been admitted.An urgent admission:You, your physician or the facility will need to call before you arescheduled to be admitted. An urgent admission is a hospital admissionby a physician due to the onset of or change in an illness, the diagnosisof an illness, or an injury.Outpatient non-emergency servicesrequiring precertification:You or your physician must call at least 14 days before the outpatientcare is provided, or the treatment or procedure is scheduled.George Mason University 2022-2023Page 5

We will provide a written notification to you and your physician of the precertification decision, where required bystate law. If your precertified services are approved, the approval is valid for 30 days as long as you remain enrolledin the plan.Coordination of Benefits (COB)Some people have health coverage under more than one health plan. If you do, we will work together with yourother plan(s) to decide how much each plan pays. This is called coordination of benefits (COB). A completedescription of the Coordination of Benefits provision is contained in the certificate issued to you.Description of BenefitsThe Plan excludes coverage for certain services and has limitations on the amounts it will pay. While this PlanSummary document will tell you about some of the important features of the Plan, other features that may beimportant to you are defined in the Certificate. To look at the full Plan description, which is contained in theCertificate issued to you, go to www.aetnastudenthealth.com.This Plan will pay benefits in accordance with any applicable Virginia Insurance Law(s).In-network coverageOut-of-network coveragePolicy year deductiblesYou have to meet your policy year deductible before this plan pays for benefits.Student 200 per policy year 250 per policy yearSpouse or domestic partner 200 per policy year 250 per policy yearEach child 200 per policy year 250 per policy yearPolicy year deductible waiverThe policy year deductible is waived for all of the following eligible health services: In-network care for Preventive care and wellness, Walk-in clinic visits, Physician and specialist services OfficeVisit, Consultant services Office Visit, Walk-in clinic visits, Outpatient mental disorders treatment office visits,Outpatient substance use office visits, and adult routine vision exam In-network care and out-of-network care for Hospital emergency room, Urgent care, Pediatric dental care, Wellnewborn nursery care, Outpatient physical, occupational, speech (including speech language therapies), andcognitive therapies, Spinal manipulation (chiropractic, osteopathic, and manipulation therapy services),Ambulance service, Pediatric vision care, and outpatient prescription drugsIndividual deductibleThis is the amount you owe for in-network and out-of-network eligible health services each policy year before theplan begins to pay for eligible health services. This policy year deductible applies separately to you and each ofyour covered dependents. After the amount you pay for eligible health services reaches the policy yeardeductible, this plan will begin to pay for eligible health services for the rest of the policy year.Eligible health services applied to the out-of-network policy year deductibles will not be applied to satisfy the innetwork policy year deductibles. Eligible health services applied to the in-network policy year deductibles will notbe applied to satisfy the out-of-network policy year deductibles.George Mason University 2022-2023Page 6

Maximum out-of-pocket limitsIn-network coverageOut-of-network coverageStudent 6,350 per policy yearNoneSpouse or domestic partner 6,350 per policy yearNoneEach child 6,350 per policy yearNoneFamily 12,700 per policy yearNoneEligible health services applied to the out-of-network maximum out-of-pocket limit will not be applied to satisfythe in-network maximum out-of-pocket limit and eligible health services applied to the in-network maximumout-of-pocket limit will not be applied to satisfy the out-of-network maximum out-of-pocket limit.Eligible health servicesIn-network coverageOut-of-network coverageRoutine physical examsPerformed at a physician’s office100% (of the negotiated charge)per visit60% (of the recognized charge)per visitNo copayment or policy yeardeductible appliesMaximum age and visit limits per policyyear through age 21Subject to any age and visit limits provided for in thecomprehensive guidelines supported by the American Academy ofPediatrics/Bright Futures/Health Resources and ServicesAdministration guidelines for children and adolescents.Covered persons age 22 and over:Maximum visits per policy year1 visitPreventive care immunizationsPerformed in a facility or at a physician'soffice100% (of the negotiated charge)per visit60% (of the recognized charge)per visitNo copayment or policy yeardeductible appliesMaximumsSubject to any age limits provided for in the comprehensiveguidelines supported by Advisory Committee on ImmunizationPractices of the Centers for Disease Control and PreventionThe following is not covered under this benefit: Any immunization that is not considered to be preventive care or recommended as preventive care, such asthose required due to employment or travelRoutine gynecological exams (including Pap smears and cytology tests)Performed at a physician’s, obstetrician(OB), gynecologist (GYN) or OB/GYN office100% (of the negotiated charge)per visit60% (of the recognized charge)per visitNo copayment or policy yeardeductible appliesMaximum visits per policy yearGeorge Mason University 2022-20231 visitPage 7

Eligible health servicesIn-network coverageOut-of-network coveragePreventive screening and counseling servicesPreventive screening and counselingservices for Obesity and/or healthy dietcounseling, Misuse of alcohol & drugs,Tobacco Products, Depression Screening,Sexually transmitted infection counseling &Genetic risk counseling for breast andovarian cancerObesity and/or healthy diet counselingMaximum visits100% (of the negotiated charge)per visit60% (of the recognized charge)per visitNo copayment or policy yeardeductible appliesAge 0-22: unlimited visits.Age 22 and older: 26 visits per 12 months, of which up to 10 visitsmay be used for healthy diet counseling.Misuse of alcohol and/or drugs counseling Maximum visits per policy year5 visitsUse of tobacco products counseling Maximum visits per policy year8 visitsDepression screening counseling Maximum visits per policy year1 visitSexually transmitted infection counseling Maximum visits per policy year2 visitsGenetic risk counseling for breast andovarian cancer limitationsRoutine cancer screeningsNot subject to any age or frequency limitations100% (of the negotiated charge)per visit60% (of the recognized charge)per visitNo copayment or policy yeardeductible appliesMaximum:Subject to any age; family history; and frequency guidelines as setforth in the most current: Evidence-based items that have in effect a rating of A or B in thecurrent recommendations of the United States PreventiveServices Task Force; and The comprehensive guidelines supported by the HealthResources and Services Administration.For details, refer to the Routine cancer screeningssection of your certificate of coverage or contact your physician orMember Services by logging in to your Aetna website atwww.aetnastudenthealth.com or calling the toll-free number onyour ID card.Lung cancer screening maximumGeorge Mason University 2022-20231 screening every 12 monthsPage 8

Eligible health servicesIn-network coverageOut-of-network coveragePreventive screening and counseling services (continued)Prenatal care services (Preventive careservices only)100% (of the negotiated charge)per visit60% (of the recognized charge)per visitNo copayment or policy yeardeductible appliesLactation support and counseling services100% (of the negotiated charge)per visit60% (of the recognized charge)per visitNo copayment or policy yeardeductible appliesLactation counseling services maximumvisits per policy year either in a group orindividual settingBreast pump supplies and accessories6 visits100% (of the negotiated charge)per item60% (of the recognized charge)per itemNo copayment or policy yeardeductible appliesFamily planning services – female contraceptives – counseling servicesFemale contraceptive counseling servicesoffice visit100% (of the negotiated charge)per visit60% (of the recognized charge)per visitNo copayment or policy yeardeductible appliesContraceptive counseling servicesmaximum visits per policy year either in agroup or individual settingFemale contraceptive prescription drugsand devices provided, administered, orremoved, by a provider during an office visit2 visits100% (of the negotiated charge)per item60% (of the recognized charge)per itemNo copayment or policy yeardeductible appliesFemale Voluntary sterilization - Inpatientprovider services100% (of the negotiated charge)Female Voluntary sterilization - Outpatientprovider services100% (of the negotiated charge)60% (of the recognized charge)No copayment or policy yeardeductible applies60% (of the recognized charge)No copayment or policy yeardeductible appliesThe following are not covered under this benefit: Services provided as a result of complications resulting from a female voluntary sterilization procedure andrelated follow-up care Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the FDA Contraception services during a stay in a hospital or other facility for medical care Male contraceptive methods, sterilization procedures or devicesGeorge Mason University 2022-2023Page 9

Eligible health servicesIn-network coverageOut-of-network coveragePhysicians and other health professionalsPhysician, specialist including ConsultantsOffice visits (non-surgical/non-preventivecare by a physician and specialist, includestelemedicine consultations)80% (of the negotiated charge)per visit60% (of the recognized charge)per visitNo policy year deductible appliesAllergy testing and treatmentAllergy testing performed at a physician’s orspecialist’s officeCovered according to the typeof benefit and the place wherethe service is receivedCovered according to the typeof benefit and the place wherethe service is receivedAllergy injections treatment performed at aphysician’s, or specialist officeCovered according to the typeof benefit and the place wherethe service is receivedCovered according to the typeof benefit and the place wherethe service is receivedAllergy sera and extracts administered viainjection at a physician’s or specialist’s officeCovered according to the typeof benefit and the place wherethe service is receivedCovered according to the typeof benefit and the place wherethe service is received80% (of the negotiated charge)60% (of the recognized charge)Physician and specialist surgical servicesInpatient surgery performed during yourstay in a hospital or birthing center by asurgeon (includes anesthesiologist,anesthetist and surgical assistant expenses)The following are not covered under this benefit: The services of any other physician who helps the operating physician A stay in a hospital (Hospital stays are covered in the Eligible health services and exclusions – Hospital and otherfacility care section) Services of another physician for the administration of a local anesthetic unless approved by the planas medically necessaryOutpatient surgery performed at aphysician’s or specialist’s office oroutpatient department of a hospital orsurgery center by a surgeon (includesanesthesiologist, anesthetist and surgicalassistant expenses)80% (of the negotiated charge)per visit60% (of the recognized charge)per visitThe following are not covered under this benefit: The services of any other physician who helps the operating physician A stay in a hospital (Hospital stays are covered in the Eligible health services and exclusions – Hospital and otherfacility care section) A separate facility charge for surgery performed in a physician’s office Services of another physician for the administration of a local anesthetic unless approved by the planas medically necessaryAlternatives to physician office visitsWalk-in clinic visits (non-emergency visit)80% (of the negotiated charge)per visit60% (of the recognized charge)per visitNo policy year deductible appliesGeorge Mason University 2022-2023Page 10

Eligible health servicesIn-network coverageOut-of-network coverageHospital and other facility careInpatient hospital (room and board) andother miscellaneous services and supplies)80% (of the negotiated charge)per admission60% (of the recognized charge)per admissionRoom and board for intensive care80% (of the negotiated charge)per admission60% (of the recognized charge)per admissionPreadmission testingCovered according to the typeof benefit and the place wherethe service is receivedCovered according to the typeof benefit and the place wherethe service is receivedIn-hospital non-surgical physician services80% (of the negotiated charge)per visit60% (of the recognized charge)per visit80% (of the negotiated charge)60% (of the recognized charge)Includes birthing center facility chargesAlternatives to hospital staysOutpatient surgery (facility charges)performed in the outpatient department ofa hospital or surgery centerThe following are not covered under this benefit: The services of any other physician who helps the operating physician A stay in a hospital (See the Hospital care – facility charges benefit in this section) A separate facility charge for surgery performed in a physician’s office Services of another physician for the administration of a local anesthetic unless approved by the plan asmedically necessaryHome Health Care80% (of the negotiated charge)per visit60% (of the recognized charge)per visitThe following are not covered under this benefit: Nursing and home health aide services or therapeutic support services provided outside of the home (such asin conjunction with school, vacation, work or recreational activities) Transportation Services or supplies provided to a minor or dependent adult when a family member or caregiver is not present Homemaker or housekeeper services Food or home delivered services Maintenance therapyHospice - Inpatient80% (of the negotiated charge)per admission60% (of the recognized charge)per admissionHospice - Outpatient80% (of the negotiated charge)per visit60% (of the recognized charge)per visitThe following are not covered under this benefit: Funeral arrangements Pastoral counseling Financial or legal counseling which includes estate planning and the drafting of a will Services which are not related to your care and may include:- Sitter or companion services for either you or other family members except for respite care- Transportation- Maintenance of the houseGeorge Mason University 2022-2023Page 11

Eligible health servicesIn-network coverageOut-of-network coverageAlternatives to hospital stays (continued)Outpatient private duty nursing80% (of the negotiated charge)per visit60% (of the recognized charge)per visitSkilled nursing facility - Inpatient80% (of the negotiated charge)per admission60% (of the recognized charge)per admission 250 copayment then the planpays 100% (of the balance of thenegotiated charge) per visitPaid the same as in-networkcoverageEmergency services and urgent careHospital emergency roomNo policy year deductible appliesThe following are not covered under this benefit: Non-emergency services in a hospital emergency room facilityImportant note: As out-of-network providers do not have a contract with us the provider may not accept payment of your costshare, (copayment/coinsurance), as payment in full. You may receive a bill for the difference between theamount billed by the provider and the amount paid by this plan. If the provider bills you for an amount aboveyour cost share, you are not responsible for paying that amount. You should send the bill to the address listedon the back of your ID card or call Member Services for an address at 1-800-878-1945 and we will resolve anypayment dispute with the provider over that amount. Make sure the ID card number is on the bill. A separate hospital emergency room copayment/coinsurance will apply for each visit to an emergency room. Ifyou are admitted to a hospital as an inpatient right after a visit to an emergency room, your emergency roomcopayment/coinsurance will be waived and your inpatient copayment/coinsurance will apply. Covered benefits that are applied to the hospital emergency room copayment/coinsurance cannot be appliedto any other copayment/coinsurance under the plan. Likewise, a copayment/coinsurance that applies to othercovered benefits under the plan cannot be applied to the hospital emergency room copayment/coinsurance. Separate copayment/coinsurance amounts may apply for certain services given to you in the hospitalemergency room that are not part of the hospital emergency room benefit. These copayment/coinsuranceamounts may be different from the hospital emergency room copayment/coinsurance. They are based on thespecific service given to you. Services given to you in the hospital emergency room that are not part of the hospital emergency room benefitmay be subject to copayment/coinsurance amounts that are different from the hospital emergency roomcopayment/coinsurance amounts.Urgent care80% (of the negotiated charge)per visit60% (of the recognized charge)per visitNo policy year deductible applies No policy year deductible appliesNon-urgent use of an urgent care providerNot coveredNot coveredThe following is not covered under this benefit: Non-urgent care in an urgent care facility (at a non-hospital freestanding facility)George Mason University 2022-2023Page 12

Eligible health servicesIn-network coverageOut-of-network coveragePediatric dental care(Limited to covered persons through the end of the month in which the person turns age 19)Type A servicesType B services100% (of the negotiated charge)per visit60% (of the recognized charge)per visitNo copayment or deductibleappliesNo policy year deductibleapplies80% (of the negotiated charge)per visit60% (of the recognized charge)per visitNo policy year deductible applies No policy year deduc

George Mason University Policy Year: 2022-2023 Policy Number: 724536 www.aetnastudenthealth.com (800) 878‐1945 . George Mason University 2022-2023 Page 2 This is a brief description of the Student Health Plan. The plan is available for the George Mason University