Aetna – PPO High Deductible 5500 (HSA Compatible)
|Member Benefits||In Network||Out of Network|
|Deductible||$5,500 Individual / $11,000 Family||$10,000 Individual / $20,000 Family|
|Co-Insurance||0% after deductible||50% after deductible (0% once out-of-pocket max is satisfied)|
|Coinsurance Maximum||$0 Individual / $0 Family||$2,500 Individual / $5,000 Family|
|Out-of-Pocket Maximum||$5,500 Individual / $11,000 Family||$12,500 Individual / $25,000 Family|
|Non-Specialist Office Visit||0% after deductible||50% after deductible|
|Specialist Visit||0% after deductible||50% after deductible|
|Hospital Admission||0% after deductible||50% after deductible|
|Outpatient Surgery||0% after deductible||50% after deductible|
|Urgent Care||0% after deductible||50% after deductible|
|Emergency Room||0% after deductible||0% after deductible|
|Maternity||Not Covered-except for pregnancy complications||Not Covered-except for pregnancy complications|
|Routine Gyn Exam (Pap/Mammogram)||0% deductible waived||50% after deductible|
|Preventive Health||$0 Copay; deductible waived||50% after deductible|
|Lab / X-Ray||0% after deductible||50% after deductible|
|Skilled Nursing||0% after deductible (30 day max per calendar year)*||50% after deductible (30 day max per calendar year)*|
|Physical / Occupational Therapy||0% after deductible (24 visits per calendar year)*||50% after deductible (24 visits per calendar year)*|
|Home Health Care||0% after deductible (30 visit max per calendar year)*||50% after deductible (30 visit max per calendar year)*|
|Durable Medical Equipment||0% after deductible (Aetna will pay $2,000 max per calendar year)*||50% after deductible (Aetna will pay $2,000 max per calendar year)*|
|Pharmacy||In Network||Out of Network|
|Pharmacy Deductible per Individual||Integrated with Medical Rx*||Integrated with Medical Rx*|
|Generic||0% after Integrated Medical / Rx Deductible||50% after Integrated Medical /Rx Deductible|
|Preferred Brand Copay||0% after Integrated Medical / Rx Deductible||50% after Integrated Medical / Rx Deductible|
|Non-Preferred Brand Copay||0% after Integrated Medical / Rx Deductible||50% after Integrated Medical / Rx Deductible|
|Calendar Year Max. per Individual||Unlimited||Unlimited|
|Self Injectables||0% after Integrated Medical / Rx Deductible||Not Covered|
* Maximum applies to combined in and out -of-network benefits.
** Copay is billed separately and not due at the time of service. Copay does not count towards co-insurance or out of pocket max.
What you need to know about your 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. To learn more about how we pay out-of-network benefits visit www.Aetna.com. Type “how Aetna pays” in the search box.
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.
The federal health care reform legislation, known as the Patient Protection and Affordable Care Act, was signed into law 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.