Aetna® health care design: Health plans 101

Health insurance was originally invented to help people manage the financial risk of catastrophic health issues. Today, health plans also help people stay healthy and get medical care when needed. At Aetna, we design health plans to make care more affordable and support overall well-being. Since everyone's health needs are different, our plans are flexible and can serve many types of people and communities.

A health plan connects members to important medical services like checkups, treatment for long-term illnesses and emergency care.

However, choosing a health plan can feel confusing. There are many things to consider, and people need to make the best choice for their health. That’s why Aetna listens to individuals, employers and others to create plans that are clear, complete and easy to use.

Plan typesEmpowering health care choices

Aetna offers several types of health plans in the U.S.; each designed for different needs:

• Commercial plans (employer-sponsored coverage): These plans are offered to individuals and their dependents through their employer and are a common way people get health insurance. Coverage, costs and benefits vary depending on the type of plan and the specific benefits your employer selects.
• Medicare Advantage: This is a government health insurance program for people aged 65 and older and some with disabilities. It is managed by private insurers, like Aetna. Medicare Advantage covers the same services as regular Medicare but often includes extra benefits like vision, dental and hearing care. Many plans also limit how much members pay out of pocket, which helps those on a fixed income.
• Medicaid: This health insurance option, funded by both state and federal governments, provides health coverage to low-income individuals, including adults, children, pregnant women and people with disabilities. Medicaid benefits vary by state but usually cover doctor visits, hospital stays, prescriptions and mental health care. It also includes long-term care, like nursing home services. Eligibility is based on income, family size and sometimes health conditions.
• Special Needs Plans (SNPs): These plans help people with specific health conditions or those who qualify for both Medicare and Medicaid (known as “dual-eligible” individuals). SNPs provide specialized care and support.
• Children’s Health Insurance Program (CHIP): CHIP provides health coverage to children in families who are not eligible for Medicaid and cannot afford private insurance. In some states, CHIP also covers pregnant individuals. It ensures children receive needed health services, such as doctor visits, vaccines and dental care.

Flexible health care design: Plan customization options

Health plans work with networks of doctors, clinicians and hospitals. Knowing the different types can help people pick the best plan for their needs:

• Health maintenance organization (HMO): HMO plans require members to use a network of doctors and hospitals. Out-of-network care is usually more expensive. Members also need a referral from a primary doctor before seeing a specialist.
• Point of service (POS): These plans have lower costs but require a referral from a primary doctor to see specialists. They allow some out-of-network care, but it can cost more.
• Exclusive provider organization (EPO): EPO plans only cover in-network care, except for emergencies. They offer fewer provider choices but lower costs.
• Preferred provider organization (PPO): PPO plans let members see any doctor, but costs are lower with in-network providers. Unlike HMO and POS plans, referrals are not required to see specialists.

Some health plans have high deductibles, meaning members pay more before insurance starts covering costs. These plans have lower monthly premiums and can be good for people who do not expect many medical visits.

People with high-deductible health plans can often open a health savings account (HSA), which lets them save pre-tax money to pay for medical expenses. An HSA works like a savings account for health care, helping people set aside funds for future medical needs.

Aetna health care design supports better health

Aetna designs health plans to meet the needs of individuals, businesses and communities. Our plans connect with CVS Health services to offer easy access to medical care and prescriptions. This improves care coordination, makes health care more convenient and leads to better health.

We also know that health is affected by more than just doctor’s visits. A person’s job, home, diet and ability to exercise all play a role. That’s why we include extra benefits for select plans to support a healthy lifestyle.

To give members extra financial protection, we offer optional coverage plans:

• Accident insurance: Pays cash benefits for unexpected injuries.
• Critical illness insurance: Helps cover costs for serious health problems like heart attacks, strokes, or cancer.
• Hospital indemnity insurance: Pays a set amount for each day a member is in the hospital.
• Dental insurance: Covers regular and major dental care, including cleanings, fillings, and crowns.
• Vision insurance: Covers eye exams, glasses, and contact lenses.

Our commitment to empowering your health

We know health care can be complicated. Aetna works to make health insurance easier to understand and use.

For people with long-term health conditions, Aetna care management programs offer personal support. Our care managers help members coordinate doctor visits, manage medications and stay on track with their health goals.

Mental health is just as important as physical health. Our plans include behavioral health services that work alongside medical care. We offer access to therapy, counseling and crisis support to help members with their mental health needs.