Skip to main content

Provider FAQs: Individual health plans

Have a question about Aetna CVS Heath Affordable Care Act (ACA) plans? Find simple answers about plan benefits, getting reimbursed and more to make your job easier.

General questions

Get up to speed with our plans and find details about where and when coverage is available.

 

A QHP is a plan that meets certain requirements under the Patient Protection and Affordable Care Act (ACA). A QHP is certified by the Centers for Medicare & Medicaid Services (CMS). QHPs have networks that are unique to these plans. Often, these networks have a smaller number of participating providers compared to our traditional networks.

Member ID cards will have “QHP” on them. The product name and the plan name are on the right side of the card. There is a dedicated member services toll-free number.

These plans will have an effective date of January 1, 2022 if a member enrolls and makes first binder payment by December 15, 2021. If a member enrolls and makes first binder payment between December 16, 2021 and January 15, 2022, their plans will be effective as of February 1, 2022.

Open Enrollment starts November 1, 2021 and ends January 15, 2022.

We have on-exchange and off-exchange plans available in all states we are entering for 2022:

 

  • Arizona (Banner|Aetna)
  • Florida
  • Georgia
  • Missouri
  • Nevada
  • North Carolina
  • Texas
  • Virginia (Innovation Health® plans in Northern Virginia and Aetna CVS Health plans in Richmond and Roanoke)

Yes, the payer ID and claim address are the same for exchange plans and are provided below:

 

  • Medical providers in Arizona, Florida, Georgia, North Carolina, Nevada:
    Aetna
    PO Box 14079
    Lexington, KY 40512-4079
  • Medical providers in Missouri, Texas, Virginia:
    Aetna
    PO Box 981106
    El Paso, TX 79998-1106

It’s easy to find out if you participate in our ACA individual health plans.

 

Aetna® providers

Check participation status

 

Banner providers

Check participation status

 

Innovation Health providers

Check participation status

 

If you’re registered with our Availity Provider Portal, you can perform most electronic transactions in the portal, including submitting claims, checking claim status and patient benefits and eligibility, requesting pre-certifications and submitting disputes and appeals.

Regardless of where the member purchased the plan, you will verify benefits or eligibility in the same way. If you’re registered with our Availity Provider Portal, you can perform most electronic transactions in the portal, including submitting claims, checking claim status and patient benefits and eligibility, requesting pre-certifications and submitting disputes and appeals.

Yes. Remember, members have no out-of-network benefits on any plan in any state except for emergencies. To find providers in the exchange network, you can use our provider search online referral directory below:

 

Aetna providers

 

Banner providers

 

Innovation Health providers

Plan benefits

Explore guidelines and policies to manage member benefits eligibility and other common tasks.

 

No, the existing claims filing limits will apply. For more information on timely filing standards, state by state, check out our insurance regulations by state resources on Aetna.com

The ID number listed on the member ID card (the one ending in “00”) is the member ID for the subscriber. When submitting inquiries or other requests (such as a claim or prior authorization request) for someone other than the subscriber, replace the “00” with the last two numbers that pertain to that other person.

 

Here’s an example:

 

Subscriber (Joseph Smith) - 320004841700

Dependent 1 (Jane Smith) - 320004841701

Dependent 2 (Daniel Smith) - 320004841702

Individual insurance plans do not coordinate with any insurance other than Medicare (for example, if someone had coverage under a Commercial plan, they would not qualify for the individual insurance plan). If the member is eligible and elected Medicare coverage, then Medicare will always be primary.

 

Individual insurance plans use Government Exclusion (GE) to coordinate with Medicare. GE is a method of determining Aetna’s payment when Medicare is primary for the member. Medicare payments are excluded from the total allowed charges. Aetna CVS Health considers the allowance based on the member’s responsibility after Medicare has considered the claim.

Most Aetna CVS Health ACA plan members will be auto-assigned a PCP except in Missouri, North Carolina and Virginia (Aetna members in Roanoke and Richmond). If they contact customer service, the selection can be made at that time, and then we will mail them a new ID card.

There are no OON benefits on any Aetna CVS Health individual plan in any state except for emergencies. If Aetna CVS Health approves something, it would be at the INN benefit and at a contracted rate (if broad network provider), or LOA negotiated. MinuteClinic® locations and some labs have a national network, so they are not considered OON if they are outside of the service area.

Payment and billing

Find helpful information about participating in our health plan network and getting reimbursed.

 

We will continue to pay any claims that occur during the first month of non-payment.

 

The grace period is different between members who receive premium subsidies (Advance Premium Tax Credit) and those who don’t:

 

  • For members who receive premium subsidies, there is a 90-day grace period.  At the start of the second month of non-payment, claims will be pended until payment is received in full.  If the member doesn’t pay, their termination date will be the last day of the “free” month (they get the first month “free’) and any claims paid after the termination date would be an overpayment.
  • For members who don’t receive premium subsidies, the grace period requirements vary between 30 and 31 days. If the member doesn’t pay, their termination date will be the last day of the prior month that the premium was paid, and any claims paid after the termination date would be an overpayment.

We'll process the claim in accordance with the plan benefits. If the member has assigned benefits, Aetna CVS Health will pay you directly. Members have no out-of-network benefits on any plan in any state except for emergencies.

Aetna CVS Health will provide reimbursement as outlined in your current contract, as applicable, or in a specific QHP rate schedule, should Network have arranged one with you (usually for facilities only). Refer to your contract agreement/amendment for details.

Legal notices

Health plans are offered or underwritten or administered by Coventry Health Plan of Florida, Inc., Aetna Health Inc. (Georgia), Aetna Life Insurance Company, Aetna Health of Utah Inc., Aetna Health Inc. (Pennsylvania), or Aetna Health Inc. (Texas) (Aetna). Aetna® is part of the CVS Health® family of companies.

Health benefits and health insurance plans contain exclusions and limitations.