Aetna is one of the nations top carriers (if not the best), and they have some of the most unique benefits and plan designs in the nation. Below is some highlights of their plans, and an in depth look at how their policies work, including what is covered and what is not.

Health Care Reform Updates


Since then,  Aetna  has periodically updated the Aetna  Advantage Plans for Individuals, Families and the Self-Employed to include any necessary  changes. It is important for you to know that your Aetna Advantage Plan will always comply with all of the federal  health  care reform  legislation.

Women’s Preventive Health Benefits – New Changes Effective August 1, 2012

As you may know,  the  legislation  includes  changes that  are being  phased in over a number of years. The latest  set of changes now  includes  coverage of Women’s  Preventive Health  Benefits.

As of August  1, 2012, all of the  following  women’s health  services are considered preventive  and  therefore generally  covered  at no cost share, when  provided  in-network:

  • Well-woman visits (annual  routine physical, annual  routine GYN exam and  prenatal visits)
  • Screening  for gestational diabetes
  • Human  Papillomavirus (HPV) DNA testing
  • Counseling for sexually transmitted infections
  • Counseling and  screening for human immunodeficiency virus (HIV)
  • Screening  and  counseling for interpersonal and  domestic violence
  • Breastfeeding support, supplies  and  counseling
  • Contraceptive methods and  counseling

Out of Network Costs

We cover the cost of care differently based on whether health care providers, such as doctors and hospitals, are “in network” or “out of network.” We want  to help you understand how much Aetna pays for your out-of-network care. At the same time, we want  to make it clear how much more you will need  to pay for this out-of-network care.

As an example, you may choose a doctor  in our network. You may choose to visit an out- of-network doctor. If you choose a doctor who is out of network, your Aetna health plan may pay some of that  doctor’s  bill.

Most of the time, you will pay a lot more money out of your own pocket  if you choose to use an out-of-network doctor  or hospital.

When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the “recognized” or “allowed” amount. For medical plans, Aetna recognizes an amount based  on what Medicare pays for these  services. The government sets the Medicare rate.

Your out-of-network doctor  sets the rate to charge you. It may be higher—sometimes much higher—than what  your Aetna plan “recognizes” or “allows.”

Your doctor  may bill you for the dollar amount that  Aetna doesn’t recognize. You must also pay any copayments, coinsurance and deductibles under  your plan.

No dollar amount above the recognized charge counts  toward your deductible or out-of-pocket maximums.

You can avoid these  extra costs by getting your care from Aetna’s broad network of health care providers. Go to and click on “Find a Doctor” on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site.

This way of paying out-of-network doctors and hospitals applies when  you choose to get care out of network. When you have no choice (for example: emergency room visit after a car accident), we will pay the bill as if you got care in network. You pay your plan’s copayments, coinsurance and deductibles

for your in-network level of benefits. Contact Aetna if your provider asks you to pay more.  You are not responsible for any outstanding balance billed by your providers for emergency services beyond your copayments, coinsurance and deductibles.

For dental plans, your share of costs for care is determined in a similar way as your medical plan, which is outlined in detail above.  If you choose an out-of-network dentist, you will pay a lot more money out of your own pocket  most of the time.

But the amount Aetna recognizes for out- of-network dentists is based  on different rates than  the medical plan. Aetna bases payments to out-of-network dentists on rates we use to begin contract negotiations with dentists in our network.

To qualify for an Aetna Advantage Plan, you  must  be:

  • At least age  19 and  under  age  64 3/4 (If applying as a couple, both  you and your spouse  must  be at least age  19 and  under  64 3/4)
  • Legal residents in a state  with products offered by the  Aetna Advantage Plans
  • Legal U.S. residents for at least six continuous months

If you qualify for an Aetna  Advantage Plan, we offer dependent  coverage under your policy for dependent children up to age  26 (except in Florida and  Nebraska, where  dependent  coverage is up to age  30; and  in Ohio, where  dependent coverage is up to age  28).

Medical Underwriting Requirements

The Aetna  Advantage Plans are not guaranteed issue plans and  require medical underwriting. Some  individuals may qualify as eligible under  the  Health Insurance Portability Accountability Act (HIPAA) for guaranteed issue plans.

All applicants, enrolling spouses and dependents are subject to medical underwriting to determine eligibility and  appropriate premium rate  level.

Aetna offers various premium rate  levels based  on the  medical underwriting of each  applicant.

Your Premium Payments

Your premium rate  is guaranteed for the  initial 12 months of your policy provided that  there  are no changes to your policy, including your area  of residence, benefit plan or addition of dependents. However,  if there  is a change in law or regulation or a judicial decision that  has an impact on the cost of providing your covered  benefits under  your policy, we reserve  the  right to change your premium rate  during this guarantee period.

10 Day Right To Review

Do not  cancel your current insurance until you are notified  that  you have been accepted for coverage. We’ll review your enrollment form or application to determine if you meet  underwriting requirements. If your application or enrollment form is denied, you’ll be notified  by mail. If your application or enrollment form is approved, you’ll be notified  by mail and  sent  an Aetna  Advantage Plan contract and  ID card.

If, after  reviewing the contract, you find that  you’re not  satisfied for any reason, simply return  the contract to us within 10 days. We will refund  any premium you’ve paid (including any contract fees or other  charges)  less the cost of any medical or dental services paid on behalf of you or any covered  dependent.

Your Coverage

Your coverage remains in effect  as long as you pay the  required premium charges on time, and as long as you maintain eligibility in the  plan. Coverage will be terminated if you become ineligible due  to any of the following circumstances:

  • Non-payment of premiums
  • Becoming a resident of a state  or location in which Aetna  Advantage Plans are not  available
  • Obtaining duplicate coverage
  • For other  reasons permissible by law

Levels of coverage and enrollment

These plans are subject to medical underwriting. To the  extent  that  you are subject to medical underwriting, the  following may occur  once  we have  evaluated your application or enrollment form:

  • You may be enrolled in your selected plan at the  lowest rate available (known  as the  standard premium charge)
  • You may be enrolled in your selected plan at a higher premium
  • You may be declined coverage (except for dependents under  age  19)

Duplicate coverage

If you are currently covered  by another carrier, you must agree  to discontinue the other  coverage before  or on the effective date  of the Aetna Advantage Plan. However,  do not cancel your current insurance until you are notified that  you have been  accepted for coverage and are certain that  you are keeping your Aetna Advantage Plan coverage.

Limitations & Exclusions


These medical plans do not  cover all health care expenses and  include exclusions and  limitations. You should refer to your plan documents to determine which health care services are covered  and  to what  extent.

The following is a partial list of services and  supplies that  are generally not  covered.  However, your plan documents may contain exceptions to this list based  on state  mandates or the  plan design or rider(s). Services and supplies that  are generally not  covered include, but  are not  limited to:

All medical  and  hospital  services not specifically covered  in, or which are limited or excluded  by your plan documents, including  costs of services before coverage begins  and  after coverage terminates

Cosmetic surgery

Custodial care

Donor egg retrieval

Infertility services and  other  related reproductive services unless specifically listed as covered  in your plan documents

Over-the-counter medications and  supplies

Weight control services including surgical procedures for the  treatment of obesity, medical treatment, and weight control/loss programs

Experimental and  investigational procedures, (except  for coverage for medically necessary  routine patient care costs  for members participating in a cancer  clinical trial)

Charges in connection with pregnancy care other  than  for pregnancy complications (unless otherwise mandated by your state)

Immunizations for travel or work

Implantable drugs and certain injectable drugs  including injectable infertility drugs


Radial keratotomy or related procedures

Reversal of sterilization

Services, supplies or counseling related to the  treatment of sexual dysfunction

Special or private duty nursing

Therapy or rehabilitation other than those  listed as covered  in the plan documents

Mental health and substance abuse coverage (unless otherwise mandated by your state)


Listed below are some of the charges and  services for which Aetna’s dental plans do not  provide coverage.

For a complete list of exclusions and limitations, refer to plan documents.

  • Dental services or supplies that  are primarily used  to alter, improve or enhance appearance (negotiated rates  for cosmetic procedures may be available when  a participating dentist is accessed)
  • Experimental services, supplies or procedures
  • Treatment of any jaw joint disorder, such as temporomandibular joint disorder
  • Replacement of lost or stolen appliances and  certain damaged appliances
  • Services that  Aetna  defines  as not necessary  for the  diagnosis, care or treatment of a condition involved
  • All other  limitations and  exclusions in your plan documents

Pre-Existing Conditions

For Applicants 19 and  older: During the  first 12 months* following your effective date  of coverage, no coverage will be provided for the  treatment of a pre-existing condition unless you have prior creditable coverage.

A pre-existing condition is an illness, disease, physical condition, or injury for which medical advice, or  treatment was recommended or received and/or  the  use of prescription drugs  of any kind within six months preceding the  effective date  of coverage. Services or supplies for the  treatment of a pre-existing condition are not  covered  for the  first 12 months after  the  member’s effective date. If the member had  continuous prior creditable coverage within the  63 days immediately preceding the  signature on the  application and meets  certain other  requirements, then  the  pre-existing condition exclusion of 12 months* may not  apply.

Compare and  save with the Member Payment Estimator

Before thinking  about health  care services, you should  know  what  they will cost. With this tool, you can find out  what you’ll be paying,  what  you’re getting and  what  you can expect  when  you have office visits or tests.  By planning ahead, you can get  the  most  from your money.

No matter where  you are or what  time of day, we’ve designed helpful  and  practical tools to make  your life a little easier.  It’s what  we call people  care.

• Review costs for tests  and  procedures by type and  locations

• See cost details based  on your health insurance plan, including copays and deductibles

• Access the  comparison feature so you can shop around

• Get ready for your upcoming procedure with helpful advice