How Aetna pays out-of-network benefits

Based on whether doctors are “in network” or “out of network” that aetna cover the cost of services differently,Aetna want to help you understand how much Aetna pays for your out-of-network care. At the same time, how much more you will need to pay for this care so aetna want to make it clear.

“In network” – This means you can save more money by using doctors who are in our network, because Aetna have a contract with that doctor or other health care provider. Aetna negotiate discounted rates with them to help you save money.

The benefits to using doctors in our network is : For the difference between their standard rates and the rate they’ve agreed to with us, so they won’t bill you.  And network doctors will handle any precertification requirements. All you have to pay is your coinsurance or copay, along with any deductible.

“Out of network” –In case we don’t know exactly what an out-of-network doctor will charge you because we do not have a contract for discounted rates with a doctor.

Your Aetna health plan may pay some of that doctor’s bill if you choose a doctor or other health care provider who is out of network. If you get care from a doctor in our network, it will usually pay less than.  you will have to handle any precertification that may be required by your plan.

Difference in what you will pay is substantial 

If you decide to use an out-of-network doctor, you will pay substantially more money out of your own pocket

A network doctor has agreed not to do that give you “balance billing.”  An out-of-network doctor can bill you for whatever Aetna does not pay that is one big reason.  You should also note that amounts billed by an out-of-network doctor above what Aetna allows for a service or procedure do not count toward your health plan’s deductible – or toward any out-of-pocket maximums. You must fully responsible for paying everything above the amount that Aetna allows for a service or procedure.

Your health plan typically will pay a smaller percentage of coinsurance than if you get care from a doctor in Aetna’s network.  You also may have to meet a separate deductible if you get care out of network. 

Finally, On what the doctor bills you, Aetna does not base its payments. In advance what your out-of-network doctor will charge ? Aetna do not know.  Instead on other methods, we base our rates.

If you choose to get your care out of network what we’ve just said applies.  if you don’t have a choice It’s different – in case, if you end up in an out-of-network emergency room after a car accident. Your deductible and coinsurance for the in-network level of benefits will be applied and when you have no choice in the doctors you see, and you should contact Aetna if your doctor asks you to pay more.  Generally, for any outstanding balance billed by your doctor in an emergency situation you are not responsible unless you have an Open Choice PPO plan.

Aetna’s out-of-network rates are determined.

On the plan you or your employer picks, how much your insurance covers for out-of-network depends?. The out-of-network benefit is based on the location of your employer’s home office If you get your health insurance through your employer. Your benefit is based on your residence If you have an Individual plan,.

Aetna pay for your health care using one of three methods, when you choose to see an out-of-network doctor, Your plan will state which method should be used. The methods are Aetna Out-Of-Network Rates (called Aetna Market Fee Schedule in some plans) or Medicare-based rates or “Reasonable Charge” and “Prevailing Charge”.



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