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
THE FEDERAL HEALTH CARE REFORM LEGISLATION, KNOWN AS THE PATIENT PROTECTION AND AFFORDABLE CARE ACT, WAS SIGNED INTO L AW ON MARCH 23, 2010 BY PRESIDENT OBAMA.
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 www.Aetna.com 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 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)
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
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
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.
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