Benefit summary

Allied Universal
802424

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.
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.
This policy, alone, does not meet Massachusetts Minimum Creditable Coverage standards.
Aetna will pay benefits only for services provided while coverage is in force, and only for medically
necessary, covered services. These benefits may be modified where necessary to meet state
mandated benefit requirements.
If you or your spouse have a health saving account, please consult your tax advisor before you enroll
about whether the Fixed Indemnity plan may affect it.

Benefit Summary
Proprietary

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 Here’s how the plan can help you:
You can lower your medical expenses by seeing a participating provider in the Aetna Open Choice® PPO
network. To locate a participating provider, call toll-free 1-800-607-3366 or visit
www.aetna.com/dse/custom/avp. If your provider participates in your comprehensive medical plan's
network, the medical plan's negotiated rate with that provider applies.
Unless otherwise indicated, all benefits and limitations are per covered person.

Covered benefit for inpatient stays

Unless otherwise stated, all inpatient daily stays begin on day two and Basic Basic Plus
count toward the plan year maximum.

Hospital stay — admission

Pays a lump sum benefit for the first day of your stay in a
$200 $1,500
non—ICU room of a hospital. 2nd admission requires 30 day
separation period from the first stay.
Maximum stays per plan year 2 2
Hospital stay — intensive care unit (ICU) — admission
Pays a lump sum benefit for the initial day of your stay in an ICU
$400 $1,500
room of a hospital. 2nd admission requires 30 day separation
period from the first stay.
Maximum stays per plan year 2 2

Hospital stay — daily

Pays a daily benefit beginning on day 2 for each day of your stay $200 $650
in a non-ICU room of a hospital.
Maximum days per plan year 365 365
Hospital stay — ICU daily
Pays a daily benefit beginning on day 2 for each day of your stay $400 $1,300
in an ICU room of a hospital.
Maximum days per plan year 365 365
Newborn routine care
Pays a lump sum benefit on the birth of your newborn with an $100 $400
inpatient stay.
Maximum days per plan year 1 1
Observation unit
$100 $100
Pays a lump sum benefit for the initial day of your observation.
Maximum stays per plan year 1 1
Substance abuse stay — daily
Pays a daily benefit beginning on day one for each day you have $200 $650
a stay in a substance abuse treatment facility.
Maximum days per plan year— shared with the hospital stay
benefit max 365 365

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 Covered benefit for inpatient stays
Unless otherwise stated, all inpatient daily stays begin on day one and Basic Basic Plus
count toward the plan year maximum.

Mental disorder stay — daily

Pays a daily benefit for each day you have a stay in a mental $200 $650
disorder treatment facility.
Maximum days per plan year — shared with the hospital stay
365 365
benefit max

Rehabilitation unit stay — daily

Pays a daily benefit beginning on day one for each day of your $200 $650
stay in a rehabilitation unit immediately after your hospital stay.

Maximum days per plan year — shared with the hospital stay
365 365
benefit max
Skilled nursing facility stay — daily
Pays a daily benefit beginning on day one for each day you $200 $650
have a stay in a skilled nursing facility.
Maximum days per plan year — shared with the hospital stay
365 365
benefit max
Hospice care — daily
Pays a daily benefit beginning on day one for each day you
$200 $650
have a stay in a hospice facility or each day you receive hospice
care.

Maximum days per plan year — shared with the hospital stay
365 365
benefit max

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 Covered benefits for surgery Basic Basic Plus
Inpatient surgery
Pays a daily benefit for each day you have an inpatient surgical
$200 $600
procedure during your stay due to an illness, accidental injury, or
cesarean section.
Maximum days per plan year 1 2
Outpatient surgery — hospital outpatient or ambulatory
surgical center
Pays a daily benefit for each day you have an outpatient surgical $200 $600
procedure due to an illness or accidental injury performed by a
physician.
Maximum days per plan year 1 2
Outpatient surgery — doctor’s office, urgent care facility or
hospital emergency room
Pays a daily benefit for each day you have an outpatient surgical $25 $100
procedure due to an illness or accidental injury performed by a
physician.
Maximum days per plan year 1 2

Covered benefits for doctor's visits Basic Basic Plus

Doctor visits — office / urgent care facility
$50 $80
Pays a daily benefit for each day you visit a physician.
Maximum days per plan year 5 7
Doctor visits — walk-in-clinic / telemedicine visit
$25 $25
Pays a daily benefit for each day you visit a physician.
Maximum days per plan year 5 7
Prescription drugs
Pays a daily benefit for each day you have a prescription filled by $20 $30
a licensed pharmacist on an outpatient basis.
Maximum days per plan year 12 18

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 Covered benefits for outpatient services Basic Basic Plus
Ambulance — ground
Pays a daily benefit for when you are transported by a licensed
$100 $100
professional ambulance company by a ground ambulance to or from
a hospital, or between medical facilities.
Maximum days per plan year 1 1
Ambulance — air
Pays a daily benefit for when you are transported by a licensed
$500 $500
professional ambulance company by Air ambulance to or from a
hospital, or between medical facilities.
Maximum days per plan year 1 1
Emergency room
Pays a daily benefit for each day you receive care in a hospital $100 $350
emergency room for an emergency medical condition.
Maximum days per plan year 2 2
Equipment and supplies
Pays a daily benefit for each day on which equipment and supplies $20 $30
are purchased and for any associated maintenance and repair.
Maximum days per plan year 5 5
X-ray and lab
$25 $110
Pays a daily benefit for each day on which you have an X-ray or lab.
Maximum days per plan year 3 3
Medical imaging
Pays a daily benefit for each day on which you have a covered $150 $150
medical imaging test.
Maximum days per plan year 1 1

Additional covered benefits Basic Basic Plus

Accidental injury treatment
Pays a benefit when you are treated in a doctor's office, hospital $100 $400
emergency room or walk-in clinic for an accidental injury.
Maximum days per plan year 1 1
Lodging
Pays for one motel / hotel room for a companion to accompany you
$100 $100
for each day of a stay.
Your stay must be more than 50 miles from your home.
Maximum days per plan year 10 10
Transportation
Pays a benefit for each day on which you travel from your residence $100 $100
more than 50 miles one way on doctor’s advice.
Maximum days per plan year 1 1

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 Health screening

Health screening
Pays a benefit for each day you receive any of the approved $50
health screening tests.

Maximum days per plan year 1

• Lipoprotein profile (serum plus HDL, LDL • Prostate Specific antigen (PSA) test
and triglycerides) • Flexible sigmoidoscopy
• Fasting blood glucose test • Digital rectal exams (DRE)
• Doppler screenings for peripheral vascular disease • Hemoccult stool analysis
(also known as arteriosclerosis) • Colonoscopy
• Carotid Doppler ultrasound • Virtual colonoscopy
• Electrocardiogram (EKG, ECG) • Carcinoembryonic antigen (CEA)
• Echocardiogram (ECHO) • Cancer Antigen (CA) Test -3
• Chest X-ray (CXR) (breast cancer)
• Thermography • Mammography
• Ultrasound screening for abdominal aortic aneurysms • Breast ultrasound
• Bone marrow screening • Cancer antigen (CA) Test 125
• Adult and child immunizations (ovarian cancer)
• HPV vaccine (Human papillomavirus) • Pap smears
• Bone mass density measurement (DEXA, DXA) • Cytologic screening
• Skin cancer screening • ThinPrep pap test
• Serum protein electrophoresis (blood test for myeloma)

Prescription drugs
We will pay the prescription drugs benefit amount shown in the schedule of benefits section of your
certificate for each day you have a prescription filled. Prescription drugs must be dispensed by a licensed
pharmacist on an outpatient basis.
The prescription drugs benefit amount will not be paid for:
• Immunization agents, biological sera, blood or blood plasma
• Any contraceptive method, device, material, or medicine
• Prescription drugs, medicine, or insulin used by, or administered to, you while you are confined as an
inpatient to any facility or institution
• Prescription drugs and medicine related to infertility
• Therapeutic devices or appliances

Portability
If your employment ends, and as a result your coverage under the policy ends, you can choose to continue
your Fixed Indemnity coverage by enabling the portability provision. Such coverage will be available to you
and any of your covered dependents no later than 30 calendar days after your coverage under the policy
ends.

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 Exclusions and limitations
This plan has exclusions and limitations. Refer to the actual policy and booklet certificate to determine
which health care 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 will not be paid for any service for an illness or accidental
injury related to the following:
1. Certain competitive or recreational activities, including but not limited to: ballooning, bungee jumping,
parachuting, skydiving
2. Any semi—professional or professional competitive athletic contest, including officiating or coaching, for
which you receive any payment
3. Act of war, riot, war
4. Operating, learning to operate or serving as a pilot or crew member of any aircraft, whether motorized or
not
5. Assault, felony, illegal occupation, or other criminal act
6. Care provided by a spouse, parent, child, sibling or any other household member
7. Cosmetic services and plastic surgery, with certain exceptions
8. Custodial care
9. Intentional self-harm or suicide, except when resulting from a diagnosed disorder
10. Violating any cellular device use laws of the state in which the accident occurred, while operating a
motor vehicle
11. Care or services received outside the United States or its territories
12. Experimental or investigational drugs, devices, treatments, or procedures
13. Education, training or retraining services or testing
14. Exams except as specifically provided in the Benefits under your plan section of the certificate
15. Dental and orthodontic care and treatment
16. Family planning services
17. Any care, prescription drugs, and medicines related to infertility
18. Nutritional supplements, including but not limited to: food items, infant formulas, vitamins
19. Outpatient cognitive rehabilitation, physical therapy, occupational therapy, or speech therapy for any
reason

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 Questions and answers

How does a Fixed Indemnity plan work?

Fixed indemnity plans have no copays, deductibles, or coinsurance. A Fixed Indemnity plan pays a fixed
amount per day or other period, with limits on the number and types of services. Once you have used up
your number of services, the plan will no longer pay for that kind of service. Payments under the Fixed
Indemnity Plan can be used for any purpose you choose. Because the plan pays a fixed amount, you may
owe the provider more than the plan pays. If you choose a preferred (in network) provider, then you may
pay less, because the provider may accept payment for the negotiated charge. Before you enroll in the
plan, please read the benefits chart in the previous pages carefully to understand what this plan will pay.

How does this Fixed Indemnity plan differ from a traditional comprehensive medical plan?
The Fixed Indemnity Plan is intended to supplement, not substitute for, comprehensive medical
coverage. Unlike most major medical plans, this plan does not have catastrophic coverage or a limit on
your out-of-pocket expenses. This means that you may have large out-of-pocket costs if you have a
serious or chronic medical condition. Because comprehensive medical plans provide more coverage,
they cost more. They typically satisfy the Affordable Care Act's mandate to maintain Minimum Essential
Coverage, but the Fixed Indemnity Plan does not.

What is considered a hospital stay?

A Stay is a period during which you are admitted as an inpatient; and are confined in a hospital, non-
hospital residential facility, hospice facility, skilled nursing facility, or rehabilitation facility; and are
charged for room, board, and general nursing services. A Stay does not include time in the hospital
because of custodial or personal needs that do not require medical skills or training. A Stay specifically
excludes time in the hospital for observation or in the emergency room unless this leads to a Stay.

Can I have the Fixed Indemnity Plan if I already have comprehensive health insurance?
Yes, the Fixed Indemnity Plan can supplement other health insurance. The Fixed Indeminty Plan will pay
the specified benefit whether or not your other health insurance pays anything for the service. The Fixed
Indeminty plan does not coordinate benefits with other coverage. If the provider participates in your
underlying health plan’s network, the provider may bill you for the rate the provider has negotiated with
the health plan and the Aetna discounted rate cannot be guaranteed.

Do these plans have COBRA continuation coverage?

Unlike a traditional health plan, the Fixed Indemnity plan does not offer COBRA continuation coverage.

What will I pay up front when I go to a healthcare provider?

A provider may require that you pay all charges in advance, and it would be up to you to submit a claim
for benefits under the plan. Remember that you are responsible for making sure the provider's bill gets
paid, even when the fixed benefit is less than provider's charges.

If I lose my employment, can I take the Fixed Indemnity Plan with me?
Yes, you are able to continue coverage under the Portability provision; however, you will need to pay
premiums directly to Aetna.

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 Questions and answers
Do I need to submit a claim?
If you see an In-Network provider, you don't need to submit a claim. Your provider will submit the claim
on your behalf and the benefits are paid to your provider. If the benefits are more than what you owe
the provider, the difference will be paid to you.

This plan pays you fixed dollar amounts regardless of the amount that the provider charges. 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.

How do I submit a claim?

Claim forms can be found online at: myaetnasupplemental.com. If you need a paper claim form
mailed to you call Customer Service at 1-888-772-9682. Completed claim forms can be mail to: Aetna
Voluntary Plans, PO Box 14079, Lexington, KY 40512-4079.

What should I do in an emergency?

In an emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility.

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 toll -
free 1-800-607-3366. We’re here to answer questions before and after you enroll.

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 Important information about your benefits
In order for the fixed indemnity benefits to be payable, the initial day of your stay and other
services must be on or after your effective date of coverage.

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 email 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, 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.

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 Important information about your benefits
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 617-521-7794 or visiting its website at www.mass.gov/doi.

Financial Sanctions Exclusions Clause: If coverage provided by this policy violates or will violate any US
UN, EU or other applicable 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
http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx.
Aetna Voluntary Plans are underwritten by Aetna Life Insurance Company (Aetna). Plan features and
availability may vary by location and are subject to change. 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.
Policy forms issued in Oklahoma and Idaho include:
GR96172, GR96173, AL VOL HPOL-Hosp 01, GR-9/9N, GR-29/29N, GR-23.

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