2018 Summary of Benefits - Home | Aetna Medicaid · · 2017-11-14Summary of Benefits . Aetna Better Health of Virginia (HMO SNP) ... Coordinated Care Plus (CCC Plus), ... • Full

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H1610-001.1 A

Summary of Benefits Aetna Better Health of Virginia (HMO SNP)

H1610, Plan 001

This is a summary of services covered by Aetna Better Health of Virginia January 1, 2018 - December 31, 2018 Aetna Better Health of Virginia is a Medicare Advantage HMO SNP plan with both a Medicare and Virginia Medicaid contract. Enrollment in the Plan depends on member eligibility and contract renewal. The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. The plans Evidence of Coverage provides a complete list of services we cover. The Evidence of Coverage is available on our website or you may call us to request a copy. To join Aetna Better Health of Virginia, you must be enrolled in Commonwealth Coordinated Care Plus (CCC Plus), entitled to Medicare Part A, and/or be enrolled in Medicare Part B, and live in our service area. Our service area includes the following: Accomack, Albemarle, Alexandria City, Alleghany, Amelia, Amherst, Appomattox, Arlington, Augusta, Bath, Bedford, Bland, Botetourt, Bristol City, Brunswick, Buchanan, Buckingham, Buena Vista City, Campbell, Caroline, Carroll, Charles City, Charlotte, Charlottesville City, Chesapeake City, Chesterfield, Clarke, Colonial Heights City, Craig, Culpeper, Cumberland, Danville City, Dickenson, Dinwiddie, Emporia City, Essex, Fairfax, Fairfax City, Falls Church City, Fauquier, Floyd, Fluvanna, Franklin, Franklin City, Frederick, Fredericksburg City, Galax City, Giles, Gloucester, Goochland, Grayson, Greene, Greensville, Halifax, Hampton City, Hanover, Harrisonburg, Henrico, Henry, Highland, Hopewell City, Isle of Wight, James City, King and Queen, King George, Kin William, Lancaster, Lee, Lexington City, Loudoun, Louisa, Lunenburg, Lynchburg City, Madison, Manassas City, Manassas Park, Martinsville City, Mathews, Mecklenburg, Middlesex, Montgomery, Nelson, New Kent, Newport News City, Norfolk City, Northampton, Northumberland, Norton City, Nottoway, Orange, Page, Patrick, Petersburg City, Pittsylvania, Poquoson City, Portsmouth City, Powhatan, Prince Edward, Prince George, Prince William, Pulaski, Radford City, Rappahannock, Richmond, Richmond City, Roanoke, Roanoke City, Rockbridge, Rockingham, Russell, Salem

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City, Scott, Shenandoah, Smyth, Southampton, Spotsylvania, Stafford, Staunton City, Suffolk City, Surry, Sussex, Tazewell, Virginia Beach City, Warren, Washington, Waynesboro, Westmoreland, Williamsburg City, Winchester City, Wise, Wythe, York counties in Virginia. Our dual-eligible Special Needs Plan is available to anyone who has both Medical Assistance from the state and Medicare.

Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

Premium and Benefits

Aetna Better Health of Virginia (HMO SNP)

What You Should Know

Monthly Plan Premium

$0 OR $25.10 per month You must continue to pay your Medicare Part B premium.

Deductible(s) The plan applies the 2018 Medicare Part A and Part B deductible amounts listed below:

Part A Inpatient hospital deductible $1,316

Part B annual deductible $183 for certain Medicare covered in-network services plan deductible

Plan deductible applies to most in-network services. CCC Plus members - you do not have any costs for Medicare-covered services, except your prescription copayments if you are enrolled in Medicare as a CCC Plus member (Medicaid). Your coinsurance, deductibles and copayments (except for Part D prescription drugs) are paid by CCC Plus (Medicaid).

Maximum Out-of-Pocket Responsibility

Our plan protects you by having yearly limits on your out-of-

The most you pay for copays, coinsurance and

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(does not include prescription drugs)

pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $6,700 for services you

receive from in-network providers.

If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the calendar year.

other costs for medical services for the year. Refer to the "Medicare & You" handbook for Medicare-covered services. For Virginia Commonwealth Coordinated Care Plus -covered services, refer to the Medicaid Coverage section in this booklet. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.

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Inpatient Hospital Coverage

The copays for hospital and Skilled Nursing Facility (SNF) benefits are based on benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In 2017 the amounts for each benefit period were $0 or: $1,316 deductible for days 1

through 60 $329 copay per day for days

61 through 90 $658 copay per day for 60

lifetime reserve days These amounts may change on January 1 of each year.

Prior authorization may be required. This benefit will begin on day one each time you are admitted to a specific facility type. A transfer within or to a facility, including Inpatient Rehabilitation, Long Term Acute Care, Inpatient Acute or Psychiatric facility is considered a new admission. You pay your cost share per admission. Services may require prior authorization. CCC Plus members - you do not have any costs for Medicare-covered services, except your prescription copayments if you are enrolled in Medicare as a CCC Plus member (Medicaid). Your coinsurance, deductibles and copayments (except for Part D prescription drugs) are paid by CCC Plus (Medicaid).

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Outpatient Hospital coverage

Outpatient hospital observation services: 0% Outpatient surgery: 0%

Prior authorization may be required.

Doctor Visits

Primary Care Provider (PCP)

0% OR 20% You must choose an in-network provider to be your Primary Care Provider (PCP). CCC Plus members - you do not have any costs for Medicare-covered services, except your prescription copayments if you are enrolled in Medicare as a CCC Plus member (Medicaid). Your coinsurance, deductibles and copayments (except for Part D prescription drugs) are paid by CCC Plus (Medicaid).

Specialists 0% OR 20% Service may require a referral or a prior authorization from your primary care provider (PCP). CCC Plus members - you do not have any costs for Medicare-covered

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services, except your prescription copayments if you are enrolled in Medicare as a CCC Plus member (Medicaid). Your coinsurance, deductibles and copayments (except for Part D prescription drugs) are paid by CCC Plus (Medicaid).

Preventive Care $0 copay Any additional preventive services approved by Medicare during the contract year will be covered.

Emergency Care 20% (up to $80) per visit If you are admitted to the hospital within 3 days you do not have to pay your share of the cost for emergency.

Urgently Needed Services

20% of the cost (up to $65) If you are admitted to the hospital within 3 days you do not have to pay your share of the cost for urgent care.

Diagnostic Services/Labs/ Imaging

Prior authorization or physicians order may be required. CCC Plus members - you do not have any costs for

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Medicare-covered services, except your prescription copayments if you are enrolled in Medicare as a CCC Plus member (Medicaid). Your coinsurance, deductibles and copayments (except for Part D prescription drugs) are paid by CCC Plus (Medicaid).

Diagnostic radiology services (e.g., MRI)

20% After you pay your plan deductible.

Lab services 20% After you pay your plan deductible.

Diagnostic tests and procedures


Outpatient X-rays 20% after you pay your plan deductible.

Hearing Services

Medicare-covered hearing exam


Service may require a referral or a prior authorization from your primary care provider (PCP).

Routine hearing exam

$0 copay

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Hearing aids $0 copay Our plan pays up to $1,000 every three years for hearing aids. You are responsible for any amount over the hearing aid coverage limit.

Dental Services Medicare Part A (Hospital Insurance) will pay for certain dental services that you get when you're in a hospital. Limited dental services: $0 copay. $500 plan coverage limit

every calendar year.

CCC Plus members - you do not have any costs for Medicare-covered services, except your prescription copayments if you are enrolled in Medicare as a CCC Plus member (Medicaid). Your coinsurance, deductibles and copayments (except for Part D prescription drugs) are paid by CCC Plus (Medicaid).

Preventive & Diagnostic dental services include the following:

Cleaning (for up to 1 every six months): $0 copay.

Dental X-ray(s) (1 every calendar year): $0 copay.

Fluoride treatment (for up to 1 per year): $0 copay.

Oral exam (for up to 1 every six months): $0 copay.

You are responsible for any amount over the dental coverage limit.

https://www.medicare.gov/coverage/dental-services.html#1367https://www.medicare.gov/coverage/dental-services.html#1367

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Comprehensive dental services include but are not limited to:

Full mouth series or Panorex xray every 3 years from the date of last full mouth series or Panorex X-ray.

Vision Services CCC Plus members - you do not have any costs for Medicare-covered services, except your prescription copayments if you are enrolled in Medicare as a CCC Plus member (Medicaid). Your coinsurance, deductibles and copayments (except for Part D prescription drugs) are paid by CCC Plus (Medicaid).

Medicare-covered eye exams

20% after you pay your plan deductible.

Routine eye exam Routine eye exam (for up to 1 every calendar year): 20% off the cost after you pay your plan deductible.

Contacts Contact lenses: $0 copay.

Our plan pays up to $200 per calendar year for contact lenses.

Eyeglasses or contact lenses

Eyeglasses or contact lenses

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after cataract surgery

after cataract surgery: $0 copay.

Mental Health Services


Inpatient visit Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental health services provided in a general hospital. The copays for hospital and Skilled Nursing Facility (SNF) benefits are based on benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will

This benefit will begin on day one each time you are admitted to a specific facility type. A transfer within or to a facility, including Inpatient Rehabilitation, Long Term Acute Care, Inpatient Acute or Psychiatric facility is considered a new admission. You pay your cost share per admission.

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be limited to 90 days. In 2017 the amounts for each benefit period were $0 or: $1,316 deductible for days 1

through 60 $329 copay per day for days

61 through 90 $658 copay per day for 60

lifetime reserve days These amounts may change for 2018.

Outpatient group therapy visit

Group therapy visit: 20% of the cost

Outpatient individual therapy

Individual therapy visit: 20% of the cost

Skilled Nursing Facility (SNF)

Our plan covers up to 100 days in a SNF. In 2017 the amounts for each benefit period were $0 or: You pay nothing for days 1

through 20 $164.50 copay per day for

days 21 through 100 These amounts may change for 2018.

Our plan covers up to 100 days in a SNF. Prior authorization may be required. CCC Plus members - you do not have any costs for Medicare-covered services, except your prescription copayments if you are enrolled in Medicare as a CCC Plus member (Medicaid).

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Your coinsurance, deductibles and copayments (except for Part D prescription drugs) are paid by CCC Plus (Medicaid).

Physical therapy

Occupational therapy visit: 0% or 20% of the cost

Physical therapy and speech and language therapy visit: 0% or 20% of the cost

After you pay your plan deductible.


Ambulance (one-way trip)

0% or 20% after you pay your plan deductible.


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Transportation You pay nothing. Our plan covers routine transportation services for certain supplemental benefits covered by Aetna Better Health (HMO SNP). Our plan will cover up to 60-oneway trips or 30 round trips every calendar year.

Transportation services can be used for these Aetna Better Health (HMO SNP) supplemental benefits*:

Chiropractic Dental Hearing aids

Medicare Part B Drugs

For Part B drugs such as chemotherapy drugs: 0% or 20% of the cost Other Part B drugs: 0% or 20% of the cost.


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Outpatient Prescription Drugs

Deductible: $0 This plan does not have a pharmacy deductible. Stage 1 Yearly Deductible Stage Because there is no deductible for the plan, this payment stage does not apply. Stage 2 Initial Coverage Stage This stage begins when you fill your first prescription of the calendar year. During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. You stay in this stage until your year-to-date out-of-pocket costs (your payments) reach $5,000. Stage 3 Coverage Gap Stage Because there is no coverage gap for the plan, this payment stage does not apply. Stage 4 Catastrophic Coverage Stage During this stage, the plan will pay all of the costs of your drugs for the rest of the calendar year (through December 31, 2018).

Initial Coverage Limit (ICL) - total amount you and the plan pay for prescription drugs before you enter the coverage gap: There is no coverage gap for this plan.

True Out-of-Pocket Threshold Amount (TrOOP) total amount you pay before reaching the catastrophic coverage level: There is no coverage gap for this plan.

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Initial Coverage If you get Extra Help with your prescription drug costs, you will pay: (Copayments may vary depending on your level of Extra Help.)

For generic drugs (including brand drugs treated as generic): either $0, or $1.25 or

$3.35 per prescription

For all other drugs: either $0, or $3.70, or $8.35 per prescription

You may get your drugs at network retail pharmacies and mail order pharmacies. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy in certain situations. Refer to the 2018 Evidence of Coverage for details. Retail Pharmacy You can get drugs the following way(s): Onemonth (31day) supply Threemonth (90day) supply

Long Term Care Pharmacy Onemonth (31day) supply

Mail Order Threemonth (90day) supply

Out of Network Pharmacy Onemonth (31day) supply

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Other Information and Benefits

Meals Aetna Better Health (HMO SNP) will provide 7 meals upon each discharge from a hospital stay. You pay nothing.

Over-the-Counter Items

$50 maximum every month for covered over-the-counter items, available through mail-order only.

Please visit our website to see our list of covered over-the-counter items.

Remote access technologies - Telehealth

Nursing hotline: Members can call our Informed Health Line after business hours and weekends to talk to a registered nurse about medical tests, procedures and treatment options. Call the Member Services phone number and select the option to speak to a nurse in after-hours messaging. You pay nothing. Telehealth Smartphone mobile app and online access to quickly talk with a doctor about non-emergency conditions 24 hours a day, seven days a week. You pay nothing.

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Wellness Programs You pay nothing. In partnership with the Foundation for Senior Living, we offer wellness programs for: Diabetes education Exercise Nutrition Smoking cessation

Call Member Services for assistance.

Chiropractic Care Routine chiropractic visit (for up to 20 every calendar year): 20%, plus the in-network deductible

Medicare coverage is limited to manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position).

Dialysis 0% or 20% of the cost Kidney Disease Education covered: 0% or 20% of the cost.


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You pay nothing. Services may require prior authorization.

Hospice You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered by Original Medicare. Please contact us for more details.

Medical Equipment/Supplies (wheelchairs, oxygen, etc.)

Diabetes monitoring supplies: 0% or 20% of the cost, plus in-network deductible.

Diabetes self-management training: 0% or 20% of the cost, plus in-network deductible.

Therapeutic shoes or inserts for people with diabetes: 0% or 20% of the cost, plus in-network deductible.

Prosthetic devices: 0% or 20% of the cost, plus in-network deductible.

Related medical supplies: 0% or 20% of the cost, plus in-network deductible.

Services may require prior authorization. CCC Plus members - you do not have any costs for Medicare-covered services, except your prescription copayments if you are enrolled in Medicare as a CCC Plus member (Medicaid). Your coinsurance, deductibles and copayments (except for Part D prescription drugs) are paid by CCC Plus (Medicaid).

Outpatient Substance Abuse

Group therapy visit: 20% of the cost, plus in-network deductible

Services may require prior authorization or a referral from your doctor.

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Individual therapy visit: or 20% of the cost, plus in-network deductible


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Medicaid Benefits Medicare Advantage Special Needs Plan for the Dual Eligible/ Commonwealth Coordinated Care 2018 Benefits In order for you to better understand your health care options, the following chart notes your charge for certain services under the Commonwealth Coordinated Care (Medicaid) as an individual who has both Medicare and Medicaid.

Benefit Virginia Commonwealth Coordinated Care Dual

Eligible You Pay:

Aetna Better Health (HMO SNP)

Inpatient Hospital Visit $0 Services may require prior authorization.

Inpatient Mental Health Care $0 Services may require prior authorization.

Skilled Nursing Facility Services

$0 Our plan covers up to 100 days in a SNF. Services may require prior authorization.

Home Health Care Visits $0 You pay nothing. Services may require prior authorization.

Primary Care Provider Visit $0 Specialist visits may require prior authorization or a referral from your doctor.

Specialist Visit $0 0% or 20% of the cost Specialist visits may require prior authorization or a referral from your doctor.

Medicare-Covered Services including Chiropractic Care Visit, Chronic/Complex Case Management, etc.

$0 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position).

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Eligible You Pay:


Routine chiropractic visit (for up to 20 every calendar year): You pay nothing. Services may require prior authorization.

Podiatry Services Visit $0 Medicare Part B covers foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Your Medicare cost is 0% or 20% of the charge, which Medicaid pays on your behalf. Aetna Better Health (HMO SNP) covers routine foot care such as cutting or removal of corns and calluses; trimming, cutting, and clipping of nails (up to 3 visits per year): You pay nothing. Services may require prior authorization or a referral from your doctor.

Outpatient Mental Health Care Visit

$0 Services may require prior authorization or a referral from your doctor.

Outpatient Substance Abuse Care Visit


Ambulatory Surgical Center or Outpatient Hospital Facility Visit


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Eligible You Pay:


Ambulance Services $0 Emergency Room Visit $0 Coverage is limited to

emergency care received in the U.S. and its territories.

Urgently Needed Care Visit $0 Coverage is limited to emergency care received in the U.S. and its territories.

Outpatient Occupational/Physical/Speech Therapy Visit


Durable Medical Equipment $0 Services may require prior authorization.

Prosthetic Devices $0 Services may require prior authorization.

Diabetes Self-Monitoring Training & Supplies (Provided as part of a PCP visit)

$0 Services may require prior authorization.

Diagnostic Tests, X-rays and Lab Services

$0 Services may require prior authorization or a referral from your doctor. The following radiology and lab services require prior authorization: PET Scans, MRI, MRA, 3D Ultrasounds, 3D Imaging, and Genetic testing.

Colorectal Screening $0 You pay nothing. Flu & Pneumonia Vaccines $0 You pay nothing. Screening Mammogram $0 You pay nothing. Pap Smear & Pelvic Exam $0 You pay nothing. Prostate Cancer Screening $0 You pay nothing. Renal Dialysis or Nutritional $0 You pay nothing.

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Eligible You Pay:


Therapy for End-Stage Renal Disease Prescription Drugs $0 Services may require prior

authorization. For Part D drugs: Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.25 copay;

or $3.35 copay For all other drugs, either: $0 copay; or $3.70 copay;

or $8.35 copay You may get your drugs at network retail pharmacies and mail order pharmacies. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy in certain

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Eligible You Pay:


situations. Refer to the 2018 Evidence of Coverage for details. Retail Pharmacy You can get drugs the following way(s): Onemonth (31day)

supply Threemonth (90day)

supply Long Term Care Pharmacy Onemonth (31day)

supply Mail Order Threemonth (90day)

supply Out of Network Pharmacy Onemonth (31day)

supply After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,000, you pay nothing for all drugs.

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Eligible You Pay:


Some covered drugs may have additional requirements or limits on coverage.

Hearing Exams, Routine Hearing Tests, Fitting Evaluations for a Hearing Aid & Hearing Aid

Available to members who are 21 and older

with prior authorization

One routine hearing exam and fitting or evaluation every 2 years; $1,000 allowance for hearing aids every 3 years.

Yearly Routine Eye Exam, Eyeglasses, Contact Lenses, Lenses and Frames

$0 Available to members

who are 21 and older, no prior authorization

required.

Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): 0% or 20% of the cost Routine eye exam (for up

to 1 every calendar year): $0 copay.

Contact lenses: $0 copay. Eyeglasses (frames and

lenses): $0 copay. Eyeglasses or contact

lenses after cataract surgery: $0 copay.

Our plan pays up to $200 per calendar year for contact lenses through HMO SNP and $100 for frames, glasses through the CCC Plus program.

Adult Emergency Dental Services

$0 See Supplemental Benefits section

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Eligible You Pay:


Nursing Facility $0 Services may require prior authorization.

Adult Preventive Dental Services

$0 Available to members who are 21 and older with no prior authorization required

Exam and cleaning 2 times per year, annual set of routine bitewing X-rays, fillings, extractions, root canal or dentures limited to $500 annually.

Compare our plan to Medicare If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Contact us For more information, please call us at the phone number below or visit us at www.aetnabetterhealth.com/Virginia. If you are not a member of this plan, call toll-free 1-855-463-0933. TTY users should call 711. From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. local time. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8p.m. local time. Current members call the number on your ID card. You can see our plans provider directory at our website at www.aetnabetterhealth.com/Virginia. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website at www.aetnabetterhealth.com/Virginia.

http://www.aetnabetterhealth.com/Virginiahttp://www.aetnabetterhealth.com/Virginia

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Aetna Better Health of Virginia has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. Out-of-network/non-contracted providers are under no obligation to treat Aetna members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.

Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal. This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premium, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and/or co-payments/co-insurance may change on January 1 of each year. See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area. If you believe that Aetna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Aetna Medicare Grievance Department, P.O. Box 14067, Lexington, KY 40512. You can also file a grievance by phone by calling the phone number on your member identification card (TTY: 711). If you need help filing a grievance, the Aetna Medicare Customer Service Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 18003681019, 8005377697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. You can also contact the Aetna Civil Rights Coordinator by phone at 1-855-348-1369, by email at [email protected], or by writing to Aetna Medicare Grievance Department, ATTN: Civil Rights Coordinator, P.O. Box 14067, Lexington, KY 40512.

https://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html

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Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).

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HAITIAN CREOLE: Si ou pale yon lt lang ki pa Angl, wap jwenn svis asistans pou lang gratis ki disponib. Vizite sitwb nou an oswa rele nan nimewo telefn ki make nan dokiman sa a.

POLISH: Jeeli nie posuguj si Pastwo jzykiem angielskim, dostpne s bezpatne usugi wsparcia jzykowego. Prosz odwiedzi nasz witryn lub zadzwoni pod numer podany w niniejszym dokumencie.

JAPANESE:

ALBANIAN: Nse nuk flisni gjuhn angleze, shrbime ndihmse gjuhsore pa pages jan n dispozicionin tuaj. Vizitoni faqen ton n internet ose merrni n telefon numrin e telefonit n kt dokument.

AMHARIC: -

ARMENIAN: ,

BENGALI:

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KHMER:

SERBO-CROATIAN: Ako govorite neki jezik koji nije engleski, dostupne su besplatne jezike usluge. Posetite nau internet stranicu ili nazovite broj telefona navedenog u ovom dokumentu.

DINKA: Na ye jam thudt tn tho Dlth, ke kuny luilooi thok path aa t thn. Nem t tn internet td ke y cl akun ctmec c gat thin n athr du yic.

DUTCH: Als u een andere taal spreekt dan Engels, is er gratis taalondersteuning beschikbaar. Bezoek onze website of bel naar het telefoonnummer in dit document.

GREEK: , . .

GUJARATI:

.

.

HMONG: Yog hais tias koj hais ib hom lus uas tsis yog lus Askiv, muaj cov kev pab

Y0001_2018_H1610_001_SB Accepted VA-17-09-31 32

cuam txhais lus dawb pub rau koj. Mus saib peb lub website los yog hu rau tus xov tooj sau teev tseg nyob rau hauv daim ntawv no.

LAO: , . .

NAVAJO: Bilag1ana bizaad doo bee y1n7[tida d00 saad n11n1 [a bee y1n7[tigo, ata hane t11 j77ke bee 1k1 idoolwo[7g77 h0l=. B44sh nits4kees7 bee na7d7kid b1 haz1n7gi 221d77l77[ 47 doodago b44sh bee hane7 bee nihich8 hod77lnih d77 naaltsoos bik117j8.

PENNSYLVANIA DUTCH: Wann du en Schprooch anners as Englisch schwetzscht, Schprooch Helfe mitaus Koscht iss meeglich. Bsuch unsere Website odder ruf die Nummer uff des Document uff.

FARSI:

.

PUNJABI: ,

' '

ROMANIAN: Dac vorbii o alt limb dect engleza, avei la dispoziie servicii gratuite de asisten lingvistic. Vizitai site-ul nostru sau sunai la numrul de telefon specificat n acest document.

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SYRIAC:

.

THAI:

UKRAINIAN: , . - , .

URDU:

YIDDISH:

, .

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Y0001_2018_H1610_001_SB Accepted VA-17-09-31 35

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2018 Summary of Benefits - Home | Aetna Medicaid · · 2017-11-14Summary of Benefits . Aetna Better Health of Virginia (HMO SNP) ... Coordinated Care Plus (CCC Plus), ... • Full