People are paying more of their health care costs these days. It’s no wonder there is a lot of interest in keeping these costs down.
A smart way to do this is to avoid using doctors and hospitals that are “out of network.” We do not have a contract for reduced rates with an out-of-network doctor or hospital. So you could end up with higher costs and more work.
Why out-of-network costs more
These are many reasons you probably will pay more out of pocket:
The health plan pays less.
Cost sharing is more.
With most plans, your coinsurance is higher for out-of-network care. Coinsurance is the part of the covered service you pay for. (E.g. the plan pays 80% of the covered amount and you pay 20% coinsurance.)
Out-of-network rates are higher.
Deductibles are separate, higher.
You’ll have more work, too
Plus, when you visit an out-of-network doctor, you handle precertification, if needed. This means more time and more paperwork for you.
Go anywhere for emergency care
Sometimes, you don’t have a choice about where you go for care. Like if you go to the emergency room for a heart attack. When you need this type of emergency care, we pay the bill as if you got care in network. You pay your plan's copay, coinsurance, and deductible at the in-network level.
Under federal health care reform (Affordable Care Act), the government will allow some exceptions to this rule. Contact us if your doctor asks you to pay more. We will help you determine if you need to pay that bill.
Know your costs before you go
Before you decide where to receive care, look up your estimated costs. It’s easy with our cost of care tools. If you’re a member, log in to your secure Aetna Navigator® website to use these tools.
How we determine what to pay for out-of-network care
The plan you or your employer pick determines how much you pay for care out of the network. The exact amount depends on the:
Take a look at some examples of how your benefits pay for care.
How health benefits are paid:
How behavioral health benefits are paid:
How dental benefits are paid:
Still have questions?
Some out-of-network care is discounted
Does your Aetna ID card have “NAP” on the front? That stands for National AdvantageTM Program. And it has benefits for you:
Check your most recent ID card to see whether your plan has the program. Some plans that used to have NAP no longer have the program.
Do you have large out-of-network claims?
Did you choose to go to an out-of-network doctor or hospital, then get surprised with a very large bill? Sometimes a provider will allow you to pay a reduced fee. Sometimes they will work out a payment plan for you. You may be able to work this out with the provider by yourself. You also can get professional support. Here’s how that works.
You can get that support if you:
Note: This applies only if you voluntarily used your out of network benefits. If you went out of network in an emergency, contact us if the provider bills you.
As an Aetna member, you can get discounted services with a claims negotiating company. The company, the Karis Group, has been helping individuals with outstanding medical bills nationally since 1996.
For an affordable fee, the Karis Group will negotiate with the provider for you. They may be able to reduce the amount you owe or arrange a payment plan. They also may be able to qualify you for programs to resolve your balance due.
As an Aetna member, you will receive significantly discounted rates for these services. They can’t guarantee they will be successful. But if they don’t get any results for you, they will refund your fee.
Are you interested in this service? Here’s how you can learn more:
While Aetna has arranged for this discount for our members, we are not part of any agreements between our members and the Karis Group. We honor your privacy. We do not share our member information with the Karis Group.
Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc., Aetna Health of California Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products.
IN CT, THIS PLAN IS ISSUED ON AN INDIVIDUAL BASIS AND IS REGULATED AS AN INDIVIDUAL HEALTH INSURANCE PLAN.
This material is for information only and is not an offer or invitation to contract. Plans may be subject to medical underwriting or other restrictions. Rates and benefits vary by location. Health benefits and health insurance plans contain exclusions and limitations. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information is believed to be accurate as of the production date; however, it is subject to change.
Policy forms issued in OK include: HMO OK COC-5 09/07, HMO/OK GA-3 11/01, HMO OK POS RIDER 08/07, GR-23 and/or GR-29/GR-29N.