We negotiate rates with doctors to help you save money. We refer to these providers (such as doctors, hospitals, and surgical centers) as being “in our network.” You can choose to see a doctor who is in our network. You can choose to see a doctor who is out of our network.
Some of our plans pay for services if you see a doctor who is not in our network. Many of those plans pay for out-of-network services based on what is called the Medicare Rate Schedule. The government maintains and determines Medicare rates. Aetna plans base their payment on a rate higher than Medicare’s. How much more may depend on exactly what plan you or your employer picks.
We will use an example to show you how we figure out that charge.
|In network||Out of network|
|Aetna member discount||($325)||No discount|
|Aetna plan pays||$360||$180|
Because Lee's doctor is in network, the doctor’s rate is set by his contract with Aetna. Lee only pays her deductible and coinsurance.
If Lee chooses to go out of network, her doctor can bill her for the amount over the Aetna allowed amount. Her plan also pays a lower coinsurance for going out of network.
Let us show you step by step how Lee's benefits are determined.
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.
When Lee chooses to go out of network, the doctor decides on his own how much to charge. Aetna must figure out how much the plan benefit is. To do that, we first look up the Medicare Rate Schedule for the procedure code her doctor billed. Then we multiply that by the percentage in your plan. This is the "recognized" or "allowed" charge for that procedure.
Let's look in the chart above. The Medicare rate was $381: Lee's plan pays 105% of the Medicare rate. $381 × 1.05 = $400. Therefore, the out-of-network allowed amount is $400.
Your 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.
We pay our portion of the allowed amount as listed in your plan. You pay your portion (called coinsurance and deductibles).
Example: Aetna member, Lee
Lee's plan has 2 levels of coverage. If Lee goes in network, Lee's plan pays 80% of her costs. If Lee chooses to goes out of network, her plan only pays 60% of the allowed amount.
This is Lee's first doctor visit of the year. She must pay her deductible. She has to pay the entire deductible BEFORE her plan starts paying.
Lee's plan has two different deductibles. If Lee goes in network, Lee must pay the first $50 of her medical costs each year. If Lee goes out of network she must pay the first $100 of those medical costs each year. This amount is called her deductible.
|In network||Out of network|
This is the charge from the doctor.
In network: This is the amount a doctor has agreed to accept with Aetna. In this example, Aetna gets you a $325 discount off the doctor's bill.
Out of network: This is the maximum amount Aetna will pay an out-of-network doctor based on the Medicare Rate Schedule.
|Lee pays her deductible
Lee's plan has two levels of deductibles:
In network: Lee pays the first $50 of her costs.
Out of network: Lee pays the first $100.
Lee pays her coinsurance
Out of network: Lee pays 40% after deductible.
|Amount still due to Lee's Doctor||$360
|Amount Lee's plan pays
Lee's plan has two levels of coverage:
In network: Lee's plan pays 80% of her costs after her deductible.
Out of network: Lee's plan pays 60% of Aetna's allowed amount after her deductible.
|Amount still due to Lee's Doctor||$0||$425|
|Extra amount Lee's doctor can bill her:
Out-of-network doctors can bill you for more than the Aetna allowed amount. $825-$400 = $425.
|Lee's Out-Of-Pocket Costs
Total of items in parantheses
Lee’s out-of-network doctor can charge her any amount he wants. He has not agreed to a contract price for the covered service. He is charging Lee $825. For our example Lee has to pay $645. Not all of the money Lee pays counts towards her out-of-pocket limit.