Member rights: Selecting your health plan FAQs

What is the difference between traditional health insurance and managed care? 
With traditional (indemnity) insurance, you have coverage for services from  any doctor or hospital at the time service is needed. You do not need a referral to see a doctor. Under managed care, doctors, hospitals and other health care providers’ contract with the health plan to form networks that deliver health care services. Normally, you will select providers from within those networks to get the maximum coverage available through the health plan.

What if I have questions about a specific health plan or service? 
Please refer to your Summary of Benefits booklet. If you cannot find the answer there, please contact our Member Services office at the toll-free number listed on your member ID card or send an e-mail to Member Services.

How can I obtain a quote on individual or family coverage?
It’s easy. Just go to our website to shop for plans.

What is a Primary Care Physician (PCP)?

For members with HMO, Open Access® HMO, QPOS, Elect Choice EPO, Open Access Elect Choice EPO, Managed Choice® POS, Open Access Managed Choice POS plans:
A PCP provides routine services, coordinates health care services, and provides referrals to specialists and for hospital services. A PCP referral is not needed to vist an OB/GYN. PCPs can be family practitioners, general practitioners, internal medicine practitioners or pediatricians. Some states have legislation that mandates that other providers be permitted to participate as PCPs.

For members with Open Choice® PPO or Traditional Choice® plans:
PCPs can be family practitioners, general practitioners, internal medicine practitioners or pediatricians. However, these plans do not require you to select a PCP.

How does Aetna's Quality Point-Of-Service® program (QPOS) work?
Our Quality Point-Of-Service program covers medical expenses whether you visit an Aetna participating provider or an out-of-network doctor or hospital. You can keep your out-of-pocket expense to a minimum when you see your participating PCP for routine care, and when he or she coordinates necessary specialty or hospital care. You also have the freedom to go directly to a PCP, specialist or hospital for medically necessary care any time you wish. If you choose that route, except in the case  of OB/GYN, you will be responsible for the deductible and coinsurance. You may self refer to an OB/GYN at anytime without penalty . Also, if the provider does not have a pre-negotiated contract with Aetna, except in the case of emergency you may be responsible for any amount in excess of the plan’s allowed amount up to the provider’s billed charges.  Please see your benefit plan booklet for details.

What are the advantages of using participating providers?
PCPs are your key to consistent, high quality medical care. Your Aetna participating PCP is familiar with your health and maintains communication about your progress with specialists to whom he or she refers you. This coordination of care helps you to receive effective treatment and medical attention.

How do I benefit when my Aetna PCP refers me to a specialist?
Referred care promotes communication between your PCP and participating specialists. When all parties are informed of your medical condition, you should receive better coordinated care. You'll also benefit from minimum out-of-pocket expense because only a small copay is required. You always have direct access to OB/GYN services without referral.

What is my cost when I visit Aetna participating providers?
Visiting your participating PCP should keep your out-of-pocket expense to a minimum. What's more, you are fully covered for specialty care and hospitalization from Aetna participating providers coordinated through your PCP. You always have direct access to OB/GYN services without referral. Your only cost may be your applicable copayment. Check your benefit plan for specifics.

What if a participating provider isn’t available to treat my condition? 
For members with HMO, Open Access HMO, QPOS, Elect Choice EPO, Open Access Elect Choice EPO, Managed Choice POS, Open Access Managed Choice POS plans:
Our networks are comprehensive, including most recognized specialties. If the type of specialty you need is not in our network, you may be referred to a specialty doctor outside the network. In this case, your PCP would contact our patient management department to approve your referral.

For members with Open Choice PPO plans:
Our networks are comprehensive, including most recognized specialties. If the type of specialty you need is not in our network, you may contact us for approval to seek treatment from a specialty doctor outside the network. If approved, your treatment would be covered at the preferred benefit level.

For members with Traditional Choice plans:
You may visit any recognized provider. Many Traditional Choice members participate in the National Advantage ProgramTM(NAP). This program can help you save money when visiting a doctor or going to a health care facility. A listing of Participating NAP providers is available through DocFind®.

Can I go to a non-participating provider? 
For members with HMO, Open Access HMO, Elect Choice EPO, Open Access Elect Choice EPO plans:
For routine care, you may visit providers only within the Aetna network. An exception is made, however, when you need emergency services. In these situations, you may visit any nonparticipating provider.

For members with QPOS, Managed Choice POS, Open Access Managed Choice POS, Open Choice PPO plans:
You may visit any nonparticipating providers. Please note that deductibles and coinsurance may apply. Also, because the provider does not have a pre-negotiated contract with Aetna, you may be responsible for any amount in excess of the plan’s allowed amount up to the provider’s billed charges. In case of emergency services, you may use participating or non-participating providers at the in-network level of cost share and Aetna will hold you harmless for any balance bill amount.

For members with Traditional Choice plans:
You may visit any recognized provider. Many Traditional Choice members participate in the National Advantage ProgramTM (NAP). This program can help you save money when visiting a doctor or going to a health care facility. A listing of Participating NAP providers is available through DocFind, our online provider directory.

What are my out-of-pocket costs if I visit a nonparticipating doctor? 
You will be responsible for the deductible and coinsurance specified in your plan. Also, because the physician does not have a pre-negotiated contract with Aetna, you may be responsible for the amount in excess of the plan’s allowed amount up to the provider’s billed charges). In addition, you may have to file a claim form for reimbursement of the covered services. In case of emergency services, you may use participating or non-participating providers at the in-network level of cost share and Aetna will hold you harmless for any balance bill amount.

What are pre-existing conditions and how do they impact coverage? 
A pre-existing condition is a health condition (other than a pregnancy) or medical problem that was diagnosed or treated during a specified timeframe prior to enrollment in a new health plan. Some pre-existing conditions may be excluded from coverage during a specified timeframe after the effective date of coverage in a new health plan. Plan documents will provide specific information on pre-existing conditions. Pre-existing condition exclusions do not apply to enrollees under the age of 19.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) helps to protect millions of Americans and their families who have pre-existing medical conditions or who might suffer discrimination in health coverage based on factors relating to their health.
HIPAA includes provisions that:

  • Limit exclusions for pre-existing conditions.
  • Prohibit discrimination against employees and dependents based on their health status.
  • Guarantee renewability and availability of health coverage to certain employees and individuals.

Do you issue policies to minors? 
No, we do not issue policies to minor children. They may, however, be covered under a policy issued to a parent.

Feedback
You are now leaving the Aetna website.

Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.

Continue >