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How an Individual Health Plan Works

An individual plan is one that you purchase on your own, not through an employer. You can buy these plans directly from Aetna or on a health insurance exchange, also called the health insurance marketplace. 

In addition, people who work for small businesses (generally 1 to 50 full-time equivalent employees) may be offered health plans through the Small Business Health Options Program (SHOP) marketplace.

The categories below explain some of the terms we use as they apply to these plans, as well as how your plan generally works. Some information may not apply to all plans. Check your summary of benefits and coverage for information specific to your plan.

Out-of-network liability and balance billing

A network is a group of health care providers. It includes doctors, specialists, dentists, hospitals, surgical centers and other facilities. These health care providers have a contract with us.

As part of the contract, they provide services to our members at a certain rate. This rate is usually much lower than what they would charge if they were not in our network. And they agree to accept the contract rate as full payment. You pay your coinsurance or copay, along with your deductible, at the contracted rate.

We list network doctors, hospitals, pharmacies and other health care professionals in our searchable online directory. Before you buy an Aetna plan, you can confirm that your doctors are in network by using this directory.

See our online provider directory

If you already have Aetna coverage, you can register or log in to your secure member account to find care near you. 

Log in or register

You also can call us at the number on the back of your Aetna ID card. We can help you to find health care in your network. 

Out-of-network coverage

We do not have contracted rates with doctors who are out of network. Therefore, an out-of-network doctor sets the rate to charge you. We do not know in advance what that rate will be. We do not base our payments on what the doctor bills you.

In some plans, out-of-network care is covered only in an emergency. Otherwise, you are responsible for the full cost of any care you receive out of network. Please check your coverage information to see whether your plan covers out-of-network care.

When you choose to see an out-of-network doctor, we may pay for your health care depending on the plan you have. Some of our plans pay for out-of-network services by looking at what Medicare would pay and adjusting that amount up or down. Our plans range from paying 90% of what Medicare would pay (that is, 10% less than Medicare would pay) to 300% (the Medicare rate multiplied by three). Some plans pay for out-of-network services based on what is called the “usual and customary” charge or "reasonable amount" rate. These plans use information from FAIR Health, Inc., a not-for-profit company that reports how much providers charge for services in any ZIP Code.

If you have Aetna coverage, you can call Member Services at the toll-free number on the back of your Aetna ID card to find out the method that your plan uses to reimburse out-of-network doctors. You also can ask for an estimate of your share of the cost for out-of-network services you are planning.

Balance billing

An out-of-network doctor can bill you for anything over what your plan pays. You are responsible for paying that bill. This is called “balance billing.” A network doctor has agreed not to use balance billing. 

Submitting claims

If you use a network doctor or hospital, your claims will be submitted by that provider.

If you see an out-of-network provider, you will need to submit a claim yourself.

You must send us a completed claim form or alternative documentation as soon as reasonably possible. Use the fax number or mailing address on the form to send it to us.

Find a claim form

Instead of completing a claim form, you may send us:

  • A description of services
  • Bill of charges from the provider
  • Any medical documents you received from your provider

If you have questions about submitting a claim, or aren’t sure where to mail it, please call the phone number on the back of your member ID card. Or, use the table below to find a phone number or mailing address.

State Market Phone Number Address City State ZIP
DC Small Group Congressional Member Services:
800-544-0526
Non Congressional Member Services: 
855-885-3289
PO Box 981106 El Paso TX 79998
DE Individual 855-586-6906 PO Box 981106 El Paso TX 79998
DE, MD Small Group 855-885-3289 PO Box 981106 El Paso TX 79998
IA, NE Individual 855-449-2889

PO Box 981106 El Paso TX 79998
VA Innovation Health 844-289-4503 PO Box 981106 El Paso TX 79998
VA Aetna Leap 855-449-2889 PO Box 981106 El Paso TX 79998
VA Small Group 866-833-2957 PO Box 14089 Lexington KY 40512

Grace periods and claims submission policies during grace periods

For non-subsidized health insurance exchange members, members who purchased plans directly from Aetna, and members with SHOP plans:

  • Premium payments are due in full each month.
  • Active members who do not receive advance payments of the premium tax credit have a 30-day grace period to pay their monthly premium.
  • Members that do not pay their monthly premium in full by the end of the 30-day grace period are terminated back to their last paid through date.
  • Partial payments are refunded.
  • No exceptions are granted.

For subsidized members:

  • To receive a subsidy, you must purchase your plan on the health insurance exchange.
  • Premium payments are due in full each month.
  • Active members who receive subsidies and do not make a premium payment on time will enter into a 90-day grace period.
  • Subsidized members that do not pay their monthly premium payments in full by the end of the 90-day grace period will be terminated back to the last day of the first month of the grace period.
  • Subsidized members who enter into the 90-day grace period will receive a 30-day reminder letter advising them of their outstanding premium, its due date, and that claims are pended until full payment is received.
  • No exceptions are granted.

Retroactive denials

A retroactive denial reverses a previously paid claim. It occurs when coverage of a service, procedure or drug is denied after the fact.

A retroactive denial can occur if premiums are not paid. For example, if your coverage lapses due to non-payment of your monthly premiums, we will not cover services provided during the unpaid time period.

Refunds of overpayments

In the event that you have overpaid for your plan coverage, you have the right to a refund.

  • Members with individual plans should call the number on their bill or their member ID card to request a refund.
  • For plans purchased through the Small Business Health Options Program (SHOP), the employer should contact the exchange or appropriate SHOP administrator to request a refund

Medical necessity/prior authorization timeframes and responsibilities

Medical necessity is used to describe care that is reasonable, necessary, or appropriate, based on evidence-based clinical standards of care.

Prior authorization or precertification for medical necessity is a process through which a health plan approves a request to access a covered benefit (such as a type of surgery, or other medical procedure) before the member accesses the benefit.

If a health care professional does not submit a request for prior authorization/medical necessity BEFORE the service or procedure is given, we may not cover the service or procedure.

We recommend that requests are made at least 2 weeks prior to the scheduled service or procedure. The below table may offer more detail, but it may not apply to plans in every state.

Situation You, your physicial or the facility will:
For non-emergency admissions Call and request precertification at least 14 days before the date you are scheduled to be admitted.
For an emergency medical condition Call prior to the outpatient care, treatment or procedure or as soon as reasonably possible. 
For an emergency admission Call within 48 hours or as soon as reasonably possible after you have been admitted. 
For an urgent admission Call before you are scheduled to be admitted. An urgent admission is a hospital admission by a physician due to the onset of or change in an illness, the diagnosis of an illness, or an injury. 
For outpatient non-emergency medical services requiring precertification Call at least 14 days fefore the outpatient care is provided, or the treatment or procedure is scheduled. 

Drug exceptions - timeframes and responsibilities

There are three types of prescription drug requirements. Exceptions can be requested for each type.

Precertification – some drugs require precertification. This means that the health plan needs to approve the prescription before it is filled.

Your doctor must request precertification and receive our decision before you can fill a prescription. Otherwise, we will not cover the cost of the drug.

Step therapy - Some drugs require step therapy. This means that you must try one or more other drugs before the step therapy drug is covered.

The other drugs are called prerequisite drugs. They are equally effective, have FDA approval and may cost less. They treat the same condition as the step therapy drug.

If you don't try the other drugs first, you may need to pay full cost for the step therapy drug.

Quantity limits - Quantity limits help your doctor and pharmacist make sure that you use your drug correctly and safely.

We use medical guidelines and FDA-approved recommendation from drug makers to set quantity limits. The quantity limit program includes:

  • Dose efficiency edits - Limits prescription coverage to one dose per day for drugs that have approval for once-daily dosing. 
  • Maximum daily dose - If a prescription is less than the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy. 
  • Quantity limits over time- Limits prescription ocverage to a specific number of units over a specific amount of time. 

You or your prescriber can request exceptions to these requirements. To submit a request, call our Precertification Department at 1-855-240-0535, or fax a request to 1-877-269-9916. You also can mail a written request to CVS Health, ATTN: Aetna PA, 1300 E. Campbell Rd., Richardson, TX 75081.

Explanation of Benefits (EOBs)

An explanation of benefits (EOB) is a statement a health plan provides to a health plan member. An EOB is not a bill. It shows the amount that the plan covers, as well as the amount a member can be expected to pay a health care provider.

An EOB is provided after the health plan receives a claim.  

Coordination of Benefits

Coordination of benefits rules are used to decide which plan pays first for people who have more than one plan. This helps coordinate coverage and allows claim information to be shared by the plans.

Covered benefits under your Aetna plan are provided regardless of whether you may have other insurance coverage. Medicare is an exception; if you also have Medicare coverage, then Medicare is the primary payor. Your Aetna coverage pays secondary to Medicare.  

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