How Aetna pays out-of-network benefits:

How much you and your plan pay often depends if the provider like a doctor, dentist or hospital is "in network" or "out of network."  You may choose a doctor who is "in network" or "out of network."  We want to help you understand how your plan works and how much more you may need to pay when you choose to get out-of-network care.  We will use examples for a doctor.

“In network” – This means we have a contract with that doctor.  The rate we agree to pay usually is much less that what the doctor would charge you if you were not an Aetna member.  The doctor agrees not to bill you for any amount over his contract rate.  All you have to pay is your coinsurance or copayments, along with any deductible.  Your network doctor will handle any precertification required by your plan.

“Out of network” – This means we do not have a contract for reduced rates with that doctor.  This is like buying a new TV at full price without a sale or coupon.  If you choose a doctor who is out of network, your Aetna health plan may pay some of that doctor's bill.  But, it will pay less than if you get care from a doctor in our network.  We don't know exactly what an out-of-network doctor will charge you.  He can charge and bill you for whatever your Aetna plan does not pay.  You will have to handle any precertification that is required by your plan.

You will pay a lot more

Most of the time, your out-of-pocket costs will be more if you get care out of network.  These are the reasons:

• Your plan may not pay any benefits if you go out of network.  Some plans cover out-of-network care only if it is an emergency.
• Many plans have a separate deductible just for out of network.  This is higher than your in-network deductible (if there is an in-network deductible at all).  That means you must meet this deductible before your plan pays any benefits.
• In most plans your coinsurance will be higher for out-of-network care.  Coinsurance is the part of the covered service you pay for.
• Your out-of-network doctor sets the rate to charge you.  That is usually higher than what your Aetna plan "recognizes" or "allows".
• An out-of-network doctor can bill you for anything over the dollar amount that Aetna "allows".  This is called “balance billing.”  A network doctor has agreed not to do that.
• What you pay when you are “balance billed” is not part of your plan's deductible.  It is not part of any cap your plan has on how much you have to pay for covered services.
• Aetna does not base its payments on what the doctor bills you.  We do not know in advance what your out-of-network doctor will charge.  Instead, we base our rates on other methods.  Read below about the types of methods for most plans.

Emergency care

Everything we’ve said applies when you choose to get care out of network. When you have no choice (for example: emergency room visit for a heart attack), we will pay the bill as if you got care in network.  You pay your plan's copayments, coinsurance, and deductibles for your in-network level of benefits.  Under federal health care reform (Affordable Care Act), the government will allow some plans an exception to this rule.  Contact Aetna if your doctor asks you to pay more.  We will help you determine if you need to pay that bill.

How your Aetna plan determines what to pay for out-of-network care

The plan you or your employer pick determines how much your plan will pay for out-of-network care.  The exact amount will depend on what method your plan uses to set the "recognized" or “allowed” amount, and what percentage the plan pays of that “allowed” amount.

Your plan will say what method and what percentage apply.  Or call Member Services at the phone number listed on your Aetna ID card.

Click on the blue links below to learn about the way your plan pays benefits.  We will walk you through an example to see how much Aetna will pay.  The example also will show how much you will pay when you choose to get care out of network.

Health benefits

• Medicare-based rates or
• “Reasonable Charge” and “Prevailing Charge” or
• Aetna Out-Of-Network Rates (also called Aetna Market Fee Schedule in some plans)

 Behavioral Health benefits

• Medicare-based rates or
• “Reasonable Charge” and “Prevailing Charge” or
• Aetna Out-Of-Network Rates (also called Aetna Market Fee Schedule in some plans)

 Dental benefits

• “Reasonable Charge” and “Prevailing Charge” 

Know Your Costs Before You Go!

Log in to your secure member website at www.aetnanavigator.com. Then simply click on “Find a Doctor, Pharmacy or Facility.”

While you’re in Navigator, don’t forget to look up your estimated costs for your next visit or service. Our payment estimators give you a personalized cost estimate. The “Estimate cost of care” link on the left sidebar will take you there.

Do you need more help?

• Ask your doctor to refer you to a network doctor or hospital
• Contact us by e-mail on your secure member website at www.aetnanavigator.com
• Call us at the number on the back of your ID card

More Information to Share

National Advantage ^TM Program (NAP)

If your Aetna ID card has “NAP” on the front, that means Aetna can get some discounts for out-of-network care through a vendor.  This is called Aetna’s National Advantage^TM Program.  If you get care from a NAP provider, the provider cannot balance bill you.  A NAP provider is out of network. The discounts mean your out-of-pocket costs may be less than other out-of-network providers.  Check your most recent ID card to see whether your plan has the program.  Some plans that used to have the program now don't.

A Simple Example

See the Network Savings Flyer.  This will compare costs between out of network and in network.

Check your plan documents for more details

Your health plan documents will tell you how we pay for out-of-network care. Or call Member Services at the phone number listed on your Aetna ID card.