How Aetna Pays Out-of-Network Benefits: Medicare

Medicare-based rates (health & behavioral health)

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.

Example: Aetna member, Lee
  In network Out of network
Doctor's bill $825 $825
Contract/allowed amount $500 $400
Aetna member discount ($325) No discount
Plan coinsurance 80% 60%
Aetna plan pays $360 $180
Lee pays $140 $645

Why did Lee pay so much more for out of network?

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.

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.

2
We find the “recognized” or “allowed” amount

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.

3
Your total costs for care

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.

Here is our example:
 
In network Out of network
Doctor's bill
This is the charge from the doctor.
$825
$825
Contract/Allowed Amount

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.
$500 $400
Lee pays her deductible
Lee's plan has two levels of deductibles:

In network: Lee pays the first $50 of her costs.
Contract amount: $500
Deductible: - $50
Amount after deductible: $450

Out of network: Lee pays the first  $100.
Allowed amount: $400
Deductible: - $100
Amount after deductible: $300
$50 $100

Lee pays her coinsurance
Lee's plan has two levels of coinsurance:

In network: Lee pays 20% after her deductible.
Amount after deductible: $450
Coinsurance %: × 20%
Coinsurance amount: $90

Out of network: Lee pays 40% after deductible.
Amount after deductible: $300
Coinsurance %: × 40%
Coinsurance amount: $120

$90 $120
Amount still due to Lee's Doctor $360
($500-$50-$90)
$605
($825-$100-$120)
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.
Amount after deductible: $450
Coinsurance %: × 80%
Coinsurance amount: $360

Out of network:  Lee's plan pays 60% of Aetna's allowed amount after her deductible.
Amount after deductible: $300
Coinsurance %: × 60%
Coinsurance amount: $180
$360 $180
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.
$0 + $425
Lee's Out-Of-Pocket Costs
Total of items in parantheses
$140
($50+$90)
$645
($100+$120+$425= $645)

How does this affect Lee’s out-of-pocket limits?

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.

  • Her out-of-network deductible counts toward her out-of-pocket limit ($100)
  • Her coinsurance counts toward her out-of-pocket limits ($120). This is Lee’s share of the allowed amount.
  • The extra amount the doctor can bill her does not count toward her out-of-pocket limit ($425). Lee must pay this extra amount billed by her doctor.

What if Lee had met her deductible?

  • In network – If Lee had met her deductible, her plan would pay 80% of the allowed $500.
  • Out of network – If Lee had met her deductible, her plan would pay 60% of the allowed $400. She still needs to pay any amount extra billed by her doctor.
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