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Out-of-network disclosures for persons covered under a fully-insured New Jerseyhealth benefits planThis summary only provides an overview of how a covered person’s health benefits plan covers out-of-networktreatment. It is only guidance to help a covered person understand their out-of-network benefits. Thissummary does not alter your coverage in any way.The covered person should refer to their group policy, certificate or evidence of coverage (if employergroup plan), or summary of benefits and coverages for more information about your out-of-network benefitsand about coverages and costs for in-network treatment.For additional information including whether a health care professional or facility is in-network or out-ofnetwork, the process to obtain of out-of-network costs and estimates for specific services please contact usat the toll-free telephone number on your member identification card.Or, visit our website at: aetna.com and select legal notices, state specific and scroll to New Jersey.Your policy covers:Medically necessarytreatment on anemergency or urgentbasis by out-ofnetwork health careprofessionals/facilitiesWhat this means:Emergency - You are covered for outof- network treatment for a medicalcondition manifesting itself by acutesymptoms of sufficient severityincluding, but not limited to, severepain; psychiatric disturbances and/orsymptoms of substance use disordersuch that a prudent layperson, whopossesses an average knowledge ofhealth and medicine, could expectthe absence of immediate medicalattention to result in: placing thehealth of the individual or unbornchild in serious jeopardy; seriousimpairment to bodily functions; orserious dysfunction of a bodily organor part. This includes any furthermedical examination and suchtreatment as may be required tostabilize the medical condition. Thisalso includes if there is inadequatetime to affect a safe transfer of apregnant woman to another hospitalbefore delivery or such transfer maypose a threat to the health or safety ofthe woman or unborn child.Urgent – You are covered for out-ofnetwork treatment of a non-lifethreatening condition that requiresHow am I protected by NJ law?Except as discussed below, you should notbe billed by an out-of-network health careprofessional or facility, for any amount inexcess of any deductible, copayment, orcoinsurance amounts (also known as “costsharing”) applicable to the same serviceswhen received in-network. If you receive abill for any other amount, please contact usat the number on your ID card, and/orfile a complaint with the Department ofBanking and Insurance:www.state.nj.us/dobi/consumer.htm.Your carrier and the out-of-network healthcare professional/facility may negotiateand settle on an amount that isultimately paid for the emergent/urgentmedical services. If that negotiatedamount exceeds what was indicated onthe initial Explanation of Benefits, yourout-of- pocket cost-sharing liability mayincrease above the amount indicated onthe initial Explanation of Benefits. Yourtotal final costs will be provided on thefinal Explanation of Benefits if settled.If an agreement cannot be reached, yourcarrier or the out-of-network health careprofessional/facility may seek to enter intobinding arbitration to determine theamount to be paid for the medicalservices. The amount awarded by the

care by a health care professionalwithin 24 hours.Your policy covers:Inadvertent outof- networkservicesarbitrator may exceed what the carrier hasalready paid to the out-of-network healthcare professional/facility; however, anyadditional amount paid by the carrierpursuant to the arbitration award will notincrease your cost-sharing liability abovethe amount indicated as your responsibilityon the second Explanation of Benefitsassociated with the last payment madeto the health care professional/facilitybefore any arbitration. If arbitration isconducted, you will also receive a finalExplanation of Benefits that will show thetotal allowed charge/amount for theservice(s).What this means:How am I protected by NJ law?Except as provided below, you should notbe billed by an out-of-network health careprofessional or facility, for any amount inexcess of any deductible, copayment, orcoinsurance amounts (also known as “costsharing”) applicable to the same serviceswhen received in-network. If you receive abill for any other amount, please contact usat the number on your ID card, and/or file acomplaint with the Department ofBanking and mYou are covered for treatment by anYour carrier and the out-of-network healthout-of- network health carecare professional/facility may negotiate andprofessional for covered servicessettle on an amount that is ultimatelywhen you use an in-network healthpaid for the inadvertent out-of-networkcare facility (e.g. hospital, ambulatory services. If that negotiated amountsurgery center, etc.) and, for anyexceeds what was indicated on the initialreason, in- network health careExplanation of Benefits, your out-ofservices are unavailable or providedpocket cost-sharing liability may increaseby an out-of-network health careabove the amount indicated on the initialprofessional in that in-network facility. Explanation of Benefits. Your total finalThis includes laboratory testingcosts will be provided on the finalordered by an in- network healthExplanation of Benefits if settled.care professional and performed by If an agreement cannot be reached,an out-of-network bio- analyticalyour carrier or the out-of-network healthlaboratory (e.g., imaging, X-rays,care professional/facility may seek toblood tests, and anesthesia).enter into binding arbitration to determinethe amount to be paid for theinadvertent out-of- network services. Theamount awarded by the arbitrator mayexceed what the carrier has already paidto an out-of-network health careprofessional/facility; however, anyadditional amount paid by the carrier

Your policy covers:Treatment fromout-of-networkhealth careprofessionals/ facilitiesif in-network health careprofessionals/facilitiesare unavailable.What this means:Plans are required to have adequatenetworks to provide you withaccess to professionals/facilitieswithin certain time/distancerequirements so you can obtainmedically necessary treatment of allillnesses or injuries covered by yourplan.pursuant to the arbitration award willnot increase your cost-sharing liabilityabove the amount indicated as yourresponsibility on the second Explanationof Benefits associated with the lastpayment made to the health careprofessional/facility before anyarbitration. If arbitration is conducted, youwill also receive a final Explanation ofBenefits that will show the total allowedcharge/amount for the service(s).How am I protected by NJ law?You can request treatment from an out-ofnetwork health care professional/facilitywhen an in-network health careprofessional/facility is unavailable throughan appeal, often called a request for an "inplan exception." Please see theDepartment of Banking and Insurance'sguide at: https://nj.gov/dobi/appeal/.

If your policy covers:Voluntaryout-of-networkservicesWhat this means:You are covered for treatment by anout-of- network health careprofessional/facility when youknowingly, voluntarily and specificallyselect an out-of-network health careprofessional/facility, even if you havethe opportunity to be serviced by anin- network health care professional/facility. We will cover voluntary outof-network service at the plancoinsurance listed in your Schedule ofBenefits. Member cost-share may varyby service and be subject to a plandeductible. Your Schedule of Benefitsdescribes your cost-share for coveredout of network services. Some coveredout-of-network services require you toprecertify them with Aetna.How am I protected by NJ law?Carriers must provide ready access toinformation about how to determinewhen a health care professional/facility isin-network. Please contact us if you haveany questions about the status of aparticular professional/facility.Additionally, health care professionals/facilities must disclose to you, in writingor on a website, the plans in which theyparticipate as in-network providers. Note,indications that a professional/facility“accepts” a certain health plan does notnecessarily indicate in- network status.So, when seeking treatment, you cancheck with both us and your prospectivehealth care professional/facility.Carriers must provide a method toenable you to be able to calculate anPlease be advised that the allowedestimate of out-of-network costs whenvoluntarily seeking to use an out-ofcharge/amount (discussed above)is not the same as the amount billednetwork health care professional/facility.by your Out-of-Network Health CareYou can contact us via the methodsabove to obtain more informationProfessional/Facility, and is usuallyregarding the allowed charge/amountsless. We calculate the allowedfor specific services if you can provide acharge/current procedural terminology (CPT)amount as explained in your Booklet/code. If you do not have a CPT code, youCertificate. Please refer to your plandocument for how the plan determines can estimate your costs by contactingallowed and recognized charges foryour health care professional for thecovered voluntary out-of-networkcodes.services.You can also log into the Aetna securemember website to use the costestimator tool to obtain an estimate ofyour costs for covered out of networkservices. If a service or procedure is notlisted in the cost estimator tool in yoursecure member website, you can obtainan estimated cost by completing theappropriate Member Request forEstimate Form on our website.To use the cost estimator, please visit oursite at: https://www.aetna.comand click the “login” button.

For a price estimate form, please visit thissection of rmation.htmlOnce on the page, scroll to New Jersey forthe applicable form.You will be responsible for paymentof: a) Your cost-sharing portion ofthe allowed charge/amount asdisclosed above; PLUS, b) thedifference between our allowedcharge/amount and the amount theout-of-network health careprofessional/facility bills for theservices (commonly referred to as the“balance bill”).You can also visit our website above formore information.Aetna complies with applicable Federal civil rights laws and does not unlawfully discriminate, exclude or treatpeople differently based on their race, color, national origin, sex, age, or disability.We provide free aids/services to people with disabilities and to people who need language assistance.If you need a qualified interpreter, written information in other formats, translation or other services, call thenumber on your ID card.If you believe we have failed to provide these services or otherwise discriminated based on a protected classnoted above, you can also file a grievance with the Civil Rights Coordinator by contacting:Civil Rights Coordinator,P.O. Box 14462, Lexington, KY 40512,1-800-648-7817, TTY: 711,Fax: 859-425-3379, CRCoordinator@aetna.com.You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for CivilRights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department ofHealth and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC20201, or at 1-800-368-1019, 800-537-7697 (TDD).Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiarycompanies, including Aetna Life Insurance Company and its affiliates (Aetna). If there is any variance between thisnotice and the plan documents, the information in your plan documents govern. 2018 Aetna Inc.95.28.300.1-NJV3 (1/19)