Medical provider or service center state location (includes joint ventures)
An individual health plan is one that you buy on your own. It is not offered by a group such as an employer or school.
You can apply for an individual health plan in three ways:
- Directly with the insurer.
- With an insurance broker or insurance navigator.
- On Healthcare.gov or a state health insurance exchange. These are also referred to as health insurance marketplaces.
The topics on this page explain:
- Common features of individual health plans
- Definitions of common terms we use
- How individual health plans generally work
- Some protections that are available to you
Some details may not apply to all plans.
Check your plan
Review your summary of benefits and coverage to find specific information for your plan. You can also check your plan policy to find covered benefits and plan provisions.
A network includes doctors, specialists, dentists, hospitals, surgical centers, and other health care providers and facilities. These health care providers have a contract with us.
As part of their contract, they provide services to our members at a certain rate. This rate is usually lower than what they would charge if they were not in our network. These providers agree to accept the contract rate as full payment. Your responsibility would be a copay, coinsurance and/or deductible, based on your plan.
We list network doctors, facilities, pharmacies, and other health care providers in our online directory. Before you buy an Aetna® plan, you can confirm that your health care providers are in network by using this directory.
Not an Aetna member?
Already a member?
You can use your member website to find care near you.
You also can call us at the number on your Aetna member ID card. We can help you find health care in your network.
We don't have contracted rates with health care providers who are out of network. That means an out-of-network health care provider sets the rate to charge you. We do not know in advance what that rate will be.
Your health plan covers network health care providers. Health care providers who are out of network are covered only in an emergency. Or, in cases where you’re in a network facility and receive services by certain out-of-network providers whose bill is a surprise.
When an out-of-network provider bills you for charges other than copays, coinsurance or the amount left on your deductible, it is called balance billing. Under federal law and some state laws, you may be protected from balance billing during an emergency or when you receive services from an out-of-network health care provider in a participating facility.
If you enroll in an Illinois PPO plan, out-of-network covered services from doctors, hospitals and other health care professionals that have not contracted with your plan may charge you more or may not be covered at all by your plan. Charging the extra amount is called balance billing. In cases like these, you may be responsible for paying for what your plan does not cover. Balance billing may be waived for covered emergency services received from out-of-network providers.
If you have Aetna coverage, you can find out how your health plan reimburses out-of-network health care providers. Call Member Services at the toll-free number on your ID card.
A claim is a request to an insurance company for payment of health care services. If you use a network health care provider or facility, that provider will submit your claims.
If you have a health plan that provides out-of-network benefits and see an out-of-network health care provider
You may need to submit the claim. Complete and mail a claim form to us as soon as reasonably possible. The address is on the form.
Instead of completing a claim form, you may send us:
- Patient name
- Types of service(s) provided
- Date(s) of service
- Conditions being treated
- Member ID number
- Bill of charges from the health care provider
- Any medical documents you received from your health care provider
- Receipts for prescription drugs not covered under the health plan, including drug name, nature of illness or injury, purchase date, quantity, prescription number, charge, pharmacy name/address, strength, dose per/day, prescribing physician's name
If required information is missing on the bill, write it on the bill and sign your name.
There are time limits to submit claims. You can find time limits by state below. You can also check with your plan. To talk with customer service, call the number on the back of your ID card or 1-800-365-7373 ${tty}.
Maximum claim filing time limits by state
Arizona, California, Delaware, Florida, Georgia, Illinois, Indiana, Kansas, Maryland, Missouri, Nevada, New Jersey, North Carolina, Ohio and Utah
You have 12 months from the date of service to file a claim.
Texas
For plan year 2022, you have 24 months from the date of service to file a claim. For plan years 2023 and 2024, you have 95 days from the date of service to file a claim.
Virginia
You have 15 months from the date of service to file a claim.
Review your policy documents for additional claim filing details.
Where do I send claims?
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Mailing address |
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Alabama, Alaska, Arizona, Arkansas, California, Florida, Georgia, Hawaii, Idaho, Louisiana, Mississippi, Nevada, New Mexico, North Carolina, Oregon, South Carolina, Utah, Tennessee, Washington |
Aetna |
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Colorado, Connecticut, Delaware, District of Columbia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Dakota, Texas, Vermont, Virginia, West Virginia, Wisconsin, Wyoming |
Aetna |
Medical provider or service center state location (includes joint ventures) |
Alabama, Alaska, Arizona, Arkansas, California, Florida, Georgia, Hawaii, Idaho, Louisiana, Mississippi, Nevada, New Mexico, North Carolina, Oregon, South Carolina, Utah, Tennessee, Washington |
|---|---|
Mailing address |
Aetna |
Medical provider or service center state location (includes joint ventures) |
Colorado, Connecticut, Delaware, District of Columbia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Dakota, Texas, Vermont, Virginia, West Virginia, Wisconsin, Wyoming |
Mailing address |
Aetna |
You’re required to pay your premium by the due date. If your premium isn’t paid by this due date, you’ll receive a grace period. A grace period is a time period when your coverage will not end even though you didn’t pay your premium.
For individual health plans, keep in mind:
- Premium payments are due in full each month.
- We’ll refund partial payments.
- Unfortunately, there are no exceptions.
If you’re enrolled in an individual health plan: If your premium isn’t paid by the due date, you’ll get a one-month grace period. During this period, your claim may be pended. If the total premium due isn’t paid by the end of the one-month grace period, your coverage will terminate back to your last paid-through date.*
If you’re enrolled in an individual health plan offered on the Health Insurance Marketplace® and receive an Advance Premium Tax Credit (APTC): If your premium isn’t paid by the due date, you’ll get a three-month grace period. We’ll pay all claims for covered services that are properly submitted during the first month of the grace period. Your claims in months two and three of your grace period may be pended* until full payment is received, if permitted by state law. If the total premium due is not paid in full by the end of the three-month grace period, your coverage will terminate back to the last day of the first month of the grace period. Your providers may balance bill you for services or the claims pended during the grade period if your coverage ends due to nonpayment. Members who have received APTC and enter the three-month grace period will receive a 30-day reminder letter about the outstanding premium.
Claims pending
During a premium grace period, if a claim is pended, that means no claims will be paid until the outstanding premium is paid in full.
A retroactive denial reverses a previously paid claim. It happens when coverage of a service, procedure or drug is denied after the fact.
A retroactive denial can happen if premiums are not paid. For example, if your coverage lapses due to nonpayment of your monthly premiums, we may not cover services provided during the unpaid period.
You can avoid retroactive denials by:
- Paying your full premium amount on time
- Talking to your provider about whether the service is a covered benefit
- Receiving your medical services from an in-network provider
If you have overpaid for your health plan coverage, you have the right to a refund. Call the number on your bill or member ID card to request a refund.
Medical necessity describes care that is reasonable, necessary and appropriate, based on evidence-based clinical standards of care.
We must approve some services and drugs before you get them. This is called prior authorization or precertification. During this process, the health plan will review the medical need for a covered benefit (such as surgery or another medical procedure) before you can access the benefit.
If a health care provider doesn't submit a prior authorization request for a service, drug or procedure requiring precertification before you access the service or procedure, we may not cover the service, drug or procedure.
Requests should be made at least two weeks before the scheduled service or procedure. This table includes more details but may not apply to health plans in every state.
Request for prior authorization and medical necessity review
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Situation |
You, your health care provider or the facility will: |
|---|---|
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For a non-emergency admission |
Request precertification at least 14 days before the date you're scheduled to be admitted. |
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For an emergency admission |
Notify the health plan within 48 hours or as soon as reasonably possible after you've been admitted. |
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For an urgent admission |
Notify the health plan before you're scheduled to be admitted. An urgent admission is an admission to a hospital, as directed by your health care provider, because you have an injury, a new illness, or a change in your current illness. |
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For an outpatient non-emergency medical service requiring precertification |
Request precertification at least 14 days before the outpatient care is provided, or the treatment or procedure is scheduled. |
Situation |
For a non-emergency admission |
|---|---|
You, your health care provider or the facility will: |
Request precertification at least 14 days before the date you're scheduled to be admitted. |
Situation |
For an emergency admission |
You, your health care provider or the facility will: |
Notify the health plan within 48 hours or as soon as reasonably possible after you've been admitted. |
Situation |
For an urgent admission |
You, your health care provider or the facility will: |
Notify the health plan before you're scheduled to be admitted. An urgent admission is an admission to a hospital, as directed by your health care provider, because you have an injury, a new illness, or a change in your current illness. |
Situation |
For an outpatient non-emergency medical service requiring precertification |
You, your health care provider or the facility will: |
Request precertification at least 14 days before the outpatient care is provided, or the treatment or procedure is scheduled. |
We typically decide on urgent prior authorization requests within 72 hours (15 days for non-urgent requests). These timeframes may vary by state.
Typical time frames to review prior authorization requests for prescription drugs
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Situation |
You, your health care provider or the facility will: |
|---|---|
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For a non-urgent/emergency drug request |
Request a prior authorization review. We’ll complete non-emergency requests within 72 hours of receiving the request. |
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For an urgent drug request |
We’ll complete urgent prior authorization requests within 24 hours of receiving the request. |
Situation |
For a non-urgent/emergency drug request |
|---|---|
You, your health care provider or the facility will: |
Request a prior authorization review. We’ll complete non-emergency requests within 72 hours of receiving the request. |
Situation |
For an urgent drug request |
You, your health care provider or the facility will: |
We’ll complete urgent prior authorization requests within 24 hours of receiving the request. |
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 health care provider 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 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. If you don't try the other drugs first, you may need to pay full cost for the step therapy drug.
Quantity limits: This helps your health care provider and pharmacist make sure that you use your drug correctly and safely.
We use medical guidelines and FDA-approved recommendations from drugmakers 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 dose, or higher than the maximum allowed dose, a message is sent to the pharmacy.
- Quantity limits over time: Limits prescription coverage to a specific number of units over a specific amount of time.
Prescription drug exceptions
Covered services are based on the drugs in your plan’s formulary (drug guide). If your request for a drug or non-formulary drug is denied, and our decision involved medical judgement, you have the right to request a medical exception.
You or your health care provider can request exceptions to these requirements. To submit a request for review by Aetna:
- Call our Precertification Department at 1-855-240-0535 ${tty} 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
You may be entitled to submit your case for review to an impartial organization outside of Aetna. This is called an Independent Review Organization (IRO). If our claim decision is one for which you can seek external review, it will be stated in the notice of adverse benefit determination. An IRO review may be requested by you, your representative, or your health care provider. The request can be submitted in writing to the address provided in the adverse benefit determination notice or by calling the number on your ID card. The IRO will send notification of its decision. We will stand by the IRO’s decision.
For a standard exception review that was denied, we will make our determination no later than 72 hours after receiving the request. For an expedited exception review that was denied, we will make our determination no later than 24 hours after receiving the request. To request an expedited review for urgent circumstances, call the number on your ID card.
An Explanation of Benefits (EOB) is a statement a health plan provides to a member. It is not a bill.
An EOB shows:
- The date you received services
- The amount the health care provider billed
- The amount the health plan covers
- The amount the health plan paid
- The amount you are expected to pay the health care provider
An EOB is provided after the health plan considers a claim.
Coordination of benefit rules are used to decide which health plan pays first for people who have more than one health plan. This helps coordinate coverage and allows claim information to be shared by the health plans.
If you’re covered under an individual health plan, some states allow us to coordinate your benefits. Other states do not allow coordination of benefits with an individual health plan. Your health plan documents will describe the process in your state.
If you have Medicare as your other health plan, Medicare will pay before your individual health plan.
Are you moving or relocating? Be sure to update your new address as soon as possible.
Keeping your address up to date helps:
- Ensure you remain eligible for coverage
- Avoid claim denials
- Prevent impact to any financial help you may be receiving
How to update your address
Choose the option based on where you enrolled in your plan. Moved outside your plan’s service area? The exchange you enrolled in will have coverage options for your new neighborhood.
Call your insurance broker if you have one, or:
If you enrolled through Aetna: Visit the enrollment and billing portal to update your address. You can also call the number on the back of your ID card for help updating your address.
- If you enrolled in Arizona, Delaware, Florida, Georgia, Illinois, Indiana, Kansas, Missouri, North Carolina, Ohio, Texas or Utah: Visit Healthcare.gov or call the Marketplace at 1-800-318-2596 for questions about updating your address and personal information.
- If your plan was purchased in California, Maryland, New Jersey, Nevada or Virginia: To update your address, you’ll need to call the state-based exchange:
- Covered California (1-800-300-1506)
- Maryland Health Connection (1-855-642-8572)
- GetCoveredNJ (1-833-677-1010)
- Nevada Health Link (1-800-547-2927)
- Virginia’s Insurance Marketplace (1-888-687-1501)
For coverage termination guidelines
If you’re in California, your coverage will terminate on the last day of your grace period.
For claims in months two and three
If you’re in Texas, we’ll continue to pay your claims in months two and three of your grace period.
Legal notices
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).
Health benefits and health insurance plans contain exclusions and limitations.