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You can 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 weren’t 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 don’t offer any out-of-network benefits. For those plans, you’re covered for out-of-network care only in an emergency. Otherwise, you need to pay 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.
You can find examples of how much you might save – on the same service – just by staying in network.
Save money with the Aetna medical provider network (PDF)
Save money with the Aetna behavioral health provider network (PDF)
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’ll 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’s usually higher than the amount your Aetna plan “recognizes” or “allows.”
We don’t base our payments on what the out-of-network doctor bills you. We don’t 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’re balance billed doesn’t count toward your deductible. And it’s 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 for care in the network). You have to 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% of the covered amount and you pay 20% coinsurance).
You’ll have more work, too
We need to approve some medical procedures before they’re done. We call this precertification.
Some common procedures that require precertification include:
- Non-emergency surgery
- Out-patient physical rehabilitation
- Inpatient hospice
- CT scans
- MRIs
If you visit a network doctor, that doctor will handle precertification for you. If you go out of network, you have to take care of precertification yourself. That means more time and more paperwork for you.
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 recognized or allowed amount to be paid by the plan (like a cost share of 80% or 60%)
To find the method and percent, check your plan documents. Or call us at the toll-free number on your member ID card.
You’re covered for emergency care. You have this coverage while you’re near your home or traveling. That includes students who’re away at school.
Here’s how it works:
- 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’ll pay the bill as if you got care in network. You pay your plan’s copays, coinsurance and deductibles for your network level of benefits.
- We’ll review the information when the claim comes in. If we think the situation wasn’t urgent, we might ask you for more information. Or we may send you a form to fill out. If so, complete the form, or call Member Services to give us details over the phone.
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.