Costs for out-of-network doctors and hospitals

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.

  • Your Aetna health benefits or insurance plan may pay part of the doctor’s bill. But it pays less of the bill than if you get care from a network doctor.
  • Some plans may not pay any benefits if you go out of network. Some plans cover out-of-network care only in an emergency.

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.

  • An out-of-network doctor sets the rate to charge you. It is usually higher than the amount your Aetna plan "recognizes" or "allows.”
  • An out-of-network doctor can bill you for anything over the amount that Aetna recognizes or allows. This is called “balance billing.” A network doctor has agreed not to do that.
  • We do not base our payments on what the out-of-network doctor bills you. We do not know in advance what the doctor will charge. 

Deductibles are separate, higher.

  • What you pay when you are balance billed does not count toward your deductible.  And it is not part of any cap your plan has on how much you have to pay for covered services.
  • Many plans have a separate out-of-network deductible. This is higher than your in-network deductible. (Sometimes, you have no deductible at all for care in the network). You must meet the out-of-network deductible before your plan pays any benefits.

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:

  • Method your plan uses to set the recognized or allowed amount
  • Percent of the allowed amount to be paid by the plan (like 80% or 60%)
  • To find the method and percent, check your plan documents. Or call Member Services at the toll-free number on your ID card.

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:

“Reasonable Charge” and “Prevailing Charge”


Still have questions?

  • 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.

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:

  • You can get discounts for out-of-network care. Your out-of-pocket costs may be less than your costs for seeing other providers who are out of network.
  • If you get care from a NAP provider, the doctor or hospital cannot balance bill you. This is true even though the NAP provider is out of network.

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:

  • Used your out-of-network benefits
  • Did not receive a discount through the NAP program, and
  • Have more than $1,000 in out-of-pocket costs for a single health care event AFTER your deductible, copay or coinsurance

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.

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