How Aetna Pays Out-of-Network Benefits

Aetna out-of-network rates (health)

Here’s a summary of how Aetna determines what to pay when your plan calls for Aetna Out-of-Network Rates.  Please note:  Some health plans also call these rates the Aetna Market Fee Schedule.

Aetna Out-of-Network Rates are Aetna’s standard rates used to begin contract negotiations with doctors in our network.  This means what Aetna pays will be closer to what we would have paid if you got care from a doctor in our network at the discounted rates.

We establish these rates with the help of many sources. We start by looking at Medicare. Then, we add other sources of data, along with a number of local market factors.

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.

We base the “recognized” or “allowed” on Aetna Out-of-Network Rates and calculate Aetna’s payment

We find the amount listed in Aetna Out-of-Network Rates for the procedure code your doctor billed..  This is the “recognized” or “allowed” charge for that procedure based on what we pay our doctors in our network.

After this, your health 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.

Example: Your plan pays 60% of the “allowed” amount when you choose to see doctors out of our network. Let’s say that you have already met your deductible.

In this example, you had an office visit with an out-of-network doctor. The doctor charged $250 for your visit.  The Aetna Out-of-Network Rate for the service you received is $100, so that is the “allowed” amount. Your plan will then pay 60% of $100, which is $60.  The doctor may bill you for the difference between her charge and what Aetna pays.

Your total costs for care

You may need to share the cost for your out-of-network care in three ways. Here’s a look at each of them:

  1. You will always need to pay any deductible amount – until that deductible is met.
  2. Your plan may also require you to pay what is called “coinsurance.” This is a percentage of the cost for any service or procedure covered by your plan. In this case, the service is your visit to an out-of-network doctor’s office.
  3. Your doctor may bill you for the difference between her original bill – and the amount paid by your plan.  This is called “balance billing.”

Example: This is your total cost based on the out-of-network doctor visit we have been talking about.

Your doctor’s bill $250
Aetna’s “allowed” or “recognized” amount $100
Plan payment (60% of Aetna’s “allowed” amount) $60
Your total out-of-pocket cost $190
 Your deductible $0 (Already met)
Your coinsurance (40% of the “allowed” amount) $40
Additional balance billed by your doctor  $150

Please Note: Only the “recognized” or “allowed” amount counts toward your health plan’s deductible — and toward any out-of-pocket maximums. This means that you are fully responsible for paying everything above the “recognized” or “allowed” amount.

Example: Let’s take another look at your out of network doctor visit. You paid a total of $190, including your deductible, coinsurance and balance bill. Your payment of $40 for coinsurance counts toward your plan’s out-of-pocket maximum. But the additional $150 you paid for your doctor’s balance bill will not count toward any of your plan’s deductible or out-of-pocket maximums.

Want to know more about Aetna Out-of-Network Rates?

Aetna Out-of-Network Rates are Aetna’s standard rates used to begin contract negotiations with doctors in our network.  These rates are developed starting with schedules of Medicare fees.  We supplement those Medicare rates with other sources of data, and apply a variety of unique local market factors to arrive at final rates in each market.

Data sources include:

  • Medicare’s Physician Fee Schedule
  • Medicare’s Clinical Lab Schedule
  • Medicare’s Durable Medical Equipment Schedule
  • Aetna’s Immunization and Injectable Schedule derived from market data including Medicare and other sources
  • Ingenix Gap Relative Value Unit data for services for which Medicare does not have a rate. This is not a fee that should be charged or paid, but a relative value of each service that is then calculated with a conversion factor supplied by Medicare

Local adjustments are dictated by market demand, such as adjustments by provider type or specialty type (such as cardiology versus pediatrics).  Aetna Out-of-Network Rates may be higher or lower than Medicare rates depending on the pricing environment of each local market and the factors noted above.


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