How Aetna pays out-of-network benefits:

Here’s a summary of how Aetna determines what to pay when your plan bases what it pays on Medicare rates, which are maintained by the government.  All Aetna plans pay at least the base Medicare rate, and usually more – exactly how much more depends on the plan you or your employer picks.

Step 1: We identify the medical procedure or service your doctor has billed 

Your doctor’s bill tells us what kind of care he or she gave to you. This is shown by the medical procedure code listed on your bill. (Procedure codes are established by the American Medical Association.)  Your doctor’s bill also tells us when and where this care was provided.

Step 2: We base the “recognized” or “allowed” on Medicare rates and calculate Aetna’s payment 

We find the amount listed on the Medicare rate schedule for the procedure code your doctor billed.  This is the “recognized” or “allowed” charge for that procedure based on what we pay our doctors in our network.

After this, your health plan pays a portion of the “allowed” amount. You can find the percentage that we pay for out-of-network care in your health plan documents.

Example: Your plan pays 60% of the “allowed” amount when you choose to see doctors out of our network. Let’s say that you have already met your deductible.

In this example, you had an office visit with an out-of-network doctor. The doctor charged $250 for your visit.  The Medicare rate for the service you received is $100, so that is the “allowed” amount.  Your plan will then pay 60% of $100, which is $60.  The doctor may bill you for the difference between her charge and what Aetna pays.

Step 3: Your total costs for care 

You may need to share the cost for your out-of-network care in up to three ways.  Here’s a look at each of them:
1.) You will always need to pay any deductible amount – until that deductible is met.
2.) Your plan may also require you to pay what is called “coinsurance.” This is a percentage of the cost for any service or procedure covered by your plan. In this case, the service is your visit to an out-of-network doctor’s office.
3.) Your doctor may bill you for the difference between her original bill – and the amount paid by your plan.  This is called “balance billing.”

Example: This is your total cost based on the out-of-network doctor visit we have been talking about.

Please Note: Only the “recognized” or “allowed” amount counts toward your health plan’s deductible – and toward any out-of-pocket maximums. This means that you are fully responsible for paying everything above the “recognized” or “allowed” amount.

Example: Let’s take another look at your out of network doctor visit. You paid a total of $190, including your deductible, coinsurance and balance bill. Your payment of $40 for coinsurance counts toward your plan’s out-of-pocket maximum. But the additional $150 you paid for your doctor’s balance bill will not count toward any of your plan’s deductible or out-of-pocket maximums.