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When you get emergency care or you’re treated by an out-of-network provider at an in-network hospital, or ambulatory surgical center or by an air ambulance provider, you are protected from surprise billing or balance billing.
Federal No Surprises Bill Act Disclosure – English (PDF)
Federal No Surprises Bill Act Disclosure – Spanish (PDF)
Utah - Your Rights and Protections Against Surprise Medical Bills (PDF)
Looking for your ID card and other plan details? Log in to your member website to find your deductible, out-of-pocket limits and other tools to manage your benefits.
If you are not sure what type of plan you have, call us at the number on your ID card. We’re here to help.
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance and/or a deductible. You may have other costs or must pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
You’re protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount. This includes copayments, deductibles and coinsurance. You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition. The exception is if you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
When you get services from certain out-of-network providers at an in-network hospital or ambulatory surgical center, those out-of-network providers may not balance bill you or ask you to sign a written notice and consent form that allows balance billing. You pay only your plan’s in-network cost-sharing amount. This applies to anesthesia, assistant surgeon, emergency medicine, hospitalist, intensivist service, laboratory, neonatology, pathology, or radiology.
If you get other services from any other out-of-network providers at in an in-network hospital or ambulatory surgical center, these out-of-network providers can’t balance bill you, unless you sign a written notice and consent form that allows balance billing and are provided with a good faith estimate of your costs from the hospital or ambulatory surgical center before services are given. If you sign the notice and consent form, you can be balance billed for out-of-network services. You are not required to sign the notice and consent form. You may seek care from an available in-network provider.
When you receive medically necessary air ambulance services from an out-of-network provider, your cost share will be the same amount that you would pay if the service was provided by an in-network provider. Any coinsurance or deductible will be based on rates that would apply if the services were supplied by an in-network provider.
Some states have surprise bill/balance billing laws. These laws apply to fully insured plans and may have impact to some self-funded plans, including state government or municipal plans and church plans. Check with your plan administrator and/or booklet to find if state law applies to your coverage.
In general, your health plan must:
If you think you’ve been wrongly billed, information and resources are available to you.
You can send complaints about potential violations of federal law or state law to the U.S. Department of Health & Human Services at 1-800-985-3059.
You can also visit the Centers for Medicare & Medicaid Services website to learn about federal guidance to end surprise bills and find help from your state agency.
If you relied on inaccurate information from our provider directories or website or that we verbally provided, we hold you harmless. For example, if you received services from a provider that you believed was in-network based on inaccurate information showing that the provider was in-network, but your claim was paid as out-of-network. In these situations, contact us — we’re here to help. The number is on the back of your ID card. We will review the claim. After review, you may be responsible only for your in-network cost share.
Aetna complies with applicable federal civil rights laws and does not unlawfully discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.
We provide free aids and services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:
Civil Rights Coordinator
P.O. Box 14462
Lexington, KY 40512
CA HMO customers:
PO Box 24030
Fresno, CA 93779
Phone: 1-800-648-7817 (TTY: 711)
Fax: 859-425-3379 (CA HMO customers: 1-860-262-7705).
You can also file a civil rights complaint with the U.S. Department of Health and Human Services Office, Office for Civil Rights Complaint Portal or at:
U.S. Department of Health and Human Services
200 Independence Avenue SW.
Room 509F, HHH Building
Washington, DC 20201
Phone: 1-800-368-1019 or 1-800-537-7697 (TDD).
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Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its affiliated companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites.
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Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its affiliated companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.
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The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. The ABA Medical Necessity Guide does not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any matters related to their coverage or condition with their treating provider.
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.
The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change.
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