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Cost of Out-of-Network Doctors & Hospitals

People are paying more of their health costs these days. It’s no wonder there is a lot of interest in keeping these costs down.

A smart way to do this is to stay in network. We negotiate rates with providers to help you save money. We refer to these providers (such as doctors, hospitals, and surgical centers) as being “in our network.”

There may be times when you decide to visit a doctor or hospital not in the Aetna network. Some plans cover out-of-network care only in an emergency — otherwise, you are responsible for the full cost. For plans that do cover out-of-network care, you’ll usually pay more than if you stayed in the network.

See how much less it can cost to stay in network

Some of our health plans pay for out-of-network services. Other plans do not (except in an emergency). The example below is for insurance plans that pay for out-of-network services.

These plans pay for out-of-network services based on an “allowed” amount. Most Aetna health insurance plans determine the allowed amount based on what Medicare would pay, or on a “reasonable” amount. Your plan documents will tell you how your plan determines the allowed amount.

This example shows you how out-of-pocket costs are calculated if you stay in network versus going out of network for the same care.

Let’s look at an $825 charge from a doctor’s visit.

In network, your cost for this visit is $140. Out of network, it’s $645 — so you pay an extra $505. Here’s why:

Cost breakdown In network Out of network
Your doctor's bill

The doctor bill is $825. For doctors in our network, we’ve contracted a price of $500 for this type of visit. This is all the doctor can collect. So you get a $325 discount at the start.

Your cost so far: $0

The doctor bill is $825. The out-of-network “allowed” amount for this type of visit is $400. The doctor can look to you to pay the rest – in this case $425. That amount is your responsibility and is called balance billing.

Your cost so far: $425

Paying your deductible

You pay your deductible for network care, which is $50.

$500 - $50 leaves $450.

Your cost so far: $50 ($0 + $50)

You pay your deductible for out-of-network care, which is $100.

Deductibles for out-of-network care are usually higher than for network care.

$400 - $100 leaves $300.

Your cost so far: $525 ($425 + $100)

What your plan pays

Now that you’ve met your deductible, your plan pays 80% of the rest. In this case, that’s $450. Your plan pays $360 (80% of $450). 

You pay the other 20%, or $90. We call this your coinsurance.

Now that you’ve met your deductible, your plan pays 60% of the remaining allowed amount. In this case, that’s $300. Your plan pays $180 (60% of $300). 

You pay the other 40%, or $120. We call this your coinsurance.

We pay a smaller percentage for out-of-network care than for network care. That means your coinsurance (the percentage you pay) is higher.

Your total cost $140 ($0+ $50 + $90) $645 ($425 + $100 + $120)

How does going out of network affect out-of-pocket limits?

An out-of-network doctor can charge any amount he or she wants. He or she has not agreed to a contract price for the covered service. In this case, the doctor is charging $825. Not all of that money counts toward your out-of-pocket limit.

  • Your out-of-network deductible ($100) counts toward your out-of-pocket limit.
  • Your coinsurance ($120) counts toward your out-of-pocket limit.
  • The extra amount the doctor can bill ($425) does not count toward your out-of-pocket limit.

How to lower your health costs

Stay in the network. Ask your doctor to refer you to a specialist, hospital or surgical center that accepts your plan. Or log in to your secure member account to search our provider directory.

Log in to search the directory 

Find out what it will cost before you go. Ask your out-of-network providers what the charge will be. For network care, your secure member account may be able to provide cost estimates. Or talk with the network provider’s office about what you may be asked to pay.

Does your member ID card have “NAP” on the front? That stands for National Advantage™ Program. And it has benefits for you:

  • You can get discounts for out-of-network care from NAP providers. Your out-of-pocket costs may be less than your costs for seeing other providers who are out of network.
  • If you get care from an NAP provider, you won’t get a balance bill. You will pay your usual cost sharing for out-of-network care.

Check your most recent ID card to see whether your plan has the program. Some plans that used to have NAP no longer have it.

Do you have large out-of-network medical bills?

Did you go to an out-of-network doctor or hospital, and then get surprised with a very large bill? Sometimes a provider will allow you to pay a reduced fee. Sometimes they will work out a payment plan for you. You may be able to work this out with the provider by yourself. You also can get professional support.

You can get support if you:

  • Used your out-of-network benefits
  • Did not receive a discount through NAP
  • Have more than $1,000 in out-of-pocket costs for a single health care event, after paying your deductible, copay or coinsurance

A claims negotiating company, the Karis Group, helps people with outstanding medical bills.

For an affordable fee, the Karis Group will negotiate with the provider for you. They may be able to reduce the amount you owe or arrange a payment plan. They also may be able to qualify you for programs to resolve your outstanding balance.

As an Aetna member, you will receive a large discount for these services. The Karis Group can’t guarantee that it will be successful. But they will refund your fee if they don’t get any results.

Learn more about the Karis Group

We have arranged for discounted services from the Karis Group, but are not part of any agreements between Aetna members and the Karis Group. We honor your privacy. We do not share our member information with the Karis Group.

Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc., Aetna Health of California Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna).  In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company.  In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156.  Each insurer has sole financial responsibility for its own products.

IN CT, THIS PLAN IS ISSUED ON AN INDIVIDUAL BASIS AND IS REGULATED AS AN INDIVIDUAL HEALTH INSURANCE PLAN.

This material is for information only and is not an offer or invitation to contract.  Plans may be subject to medical underwriting or other restrictions.  Rates and benefits vary by location.  Health benefits and health insurance plans contain exclusions and limitations.  Providers are independent contractors and are not agents of Aetna.  Provider participation may change without notice.  Aetna does not provide care or guarantee access to health services.  Information is believed to be accurate as of the production date; however, it is subject to change.

Policy forms issued in OK include:  HMO OK COC-5 09/07, HMO/OK GA-3 11/01, HMO OK POS RIDER 08/07, GR-23 and/or GR-29/GR-29N.

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