Network and Out of Network Care

Save money by staying in network

Maybe you’ve read that one of the best ways to save on health care costs is to “stay in network.” But you’re not sure what that means.

You’re not alone. Many people find the term confusing. We’re here to help you understand.

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 you were not an Aetna member. And they agree to accept the contract rate as full payment. You pay your coinsurance or copay along with your deductible.

Some plans do not offer any out-of-network benefits. For those 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.

The information on this page is for plans that offer both network and out-of-network coverage.

How much you can save

You can see detailed examples of how much you might save – on the same service – just by staying in network.

Save money with Aetna’s medical provider network

Save money with Aetna’s behavioral health provider network

Why out-of-network care costs more

There may be times when you decide to visit a doctor not in the Aetna network. If you go out of network, your out-of-pocket costs are usually higher. There are many reasons you will pay more if you go outside the network. Keep reading to learn more.

The health plan pays less

Your Aetna health benefits or insurance plan may pay part of the doctor’s bill. But it pays less of the bill than it would if you got care from a network doctor.

Also, some plans cover out-of-network care only in an emergency.

Out-of-network rates are higher

An out-of-network doctor sets the rate to charge you. It is usually higher than the amount your Aetna plan “recognizes” or “allows.”

We do not base our payments on what the out-of-network doctor bills you. We do not know in advance what the doctor will charge.

An out-of-network doctor can bill you for anything over the amount that Aetna recognizes or allows. This is called “balance billing.” A network doctor has agreed not to do that.

Cost sharing is more

What you pay when you are balance billed does not count toward your deductible. And it is not part of any cap your plan has on how much you have to pay for covered services.

Many plans have a separate out-of-network deductible. This is higher than your network deductible (sometimes, you have no deductible at all for care in the network). You must meet the out-of-network deductible before your plan pays any out-of-network benefits.

With most plans, your coinsurance is also higher for out-of-network care. Coinsurance is the part of the covered service you pay after you reach your deductible (for example, the plan pays 80 percent of the covered amount and you pay 20 percent coinsurance).

You’ll have more work, too

We need to approve some medical procedures before they are done. We call this precertification.

Some common procedures that require precertification include non-emergency surgery, out-patient physical rehabilitation, inpatient hospice, CT scans, and MRIs.

If you visit a network doctor, that doctor will handle precertification for you. If you go out of network, you must take care of precertification yourself. That means more time and more paperwork for you.

How we determine what to pay for out-of-network care

The plan you have determines how much you pay for out-of-network care. The exact amount depends on:

  • The method your plan uses to set the “recognized” or “allowed” amount
  • The percent of the allowed amount to be paid by the plan (like 80 percent or 60 percent).

Your plan may base the allowed amount on:

  • Medicare-based rates, which are determined and maintained by the government
  • “Reasonable,”, “usual and customary” and “prevailing” charges, which are obtained from a database of provider charges
  • Other types of rate schedules

To find the method and percent, check your plan documents. Or contact us at the toll-free number on your member ID card.

Read more about how we pay for out-of-network benefits 

See how we might calculate costs for an out-of-network office visit

You are covered for emergency care

  • You are covered for emergency care. You have this coverage while you are near your home or traveling. That includes students who are away at school.
  • When you need emergency care (for example, due to a heart attack or car accident), go to any doctor, walk-in clinic, urgent care center or emergency room. When you have no choice, we will pay the bill as if you got care in network. You pay your plan’s copayments, coinsurance and deductibles for your network level of benefits.
  • We’ll review the information when the claim comes in. If we think the situation was not urgent, we might ask you for more information and may send you a form to fill out. Please complete the form, or call Member Services to give us the information over the phone.

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