Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. The member's benefit plan determines coverage. ![]() The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Members should discuss any matters related to their coverage or condition with their treating provider.Įach benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Treating providers are solely responsible for medical advice and treatment of members. The ABA Medical Necessity Guide does not constitute medical advice. The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. That means more time and more paperwork for you.īy clicking on “I Accept”, I acknowledge and accept that: If you go out of network, you must take care of precertification yourself. If you visit a network doctor, that doctor will handle precertification for you. Some common procedures that require precertification include non-emergency surgery, out-patient physical rehabilitation, inpatient hospice, CT scans, and MRIs. We need to approve some medical procedures before they are done. Coinsurance is the part of the covered service you pay after you reach your deductible (for example, the plan pays 80 percent of the covered amount and you pay 20 percent coinsurance). With most plans, your coinsurance is also higher for out-of-network care. You must meet the out-of-network deductible before your plan pays any out-of-network benefits. This is higher than your network deductible (sometimes, you have no deductible at all for care in the network). Many plans have a separate out-of-network deductible. And it is not part of any cap your plan has on how much you have to pay for covered services. What you pay when you are balance billed does not count toward your deductible. This is called “balance billing.” A network doctor has agreed not to do that. We do not know in advance what the doctor will charge.Īn out-of-network doctor can bill you for anything over the amount that Aetna recognizes or allows. We do not base our payments on what the out-of-network doctor bills you. It is usually higher than the amount your Aetna plan “recognizes” or “allows.” But it pays less of the bill than it would if you got care from a network doctor.Īlso, some plans cover out-of-network care only in an emergency.Īn out-of-network doctor sets the rate to charge you. Your Aetna health benefits or insurance plan may pay part of the doctor’s bill. There are many reasons you will pay more if you go outside the network. If you go out of network, your out-of-pocket costs are usually higher. There may be times when you decide to visit a doctor not in the Aetna network. The information on this page is for plans that offer both network and out-of-network coverage. Otherwise, you are responsible for the full cost of any care you receive out of network. For those plans, out-of-network care is covered only in an emergency. Some plans do not offer any out-of-network benefits. You pay your coinsurance or copay along with your deductible. And they agree to accept the contract rate as full payment. This rate is usually much lower than what they would charge if you were not an Aetna member. ![]() ![]() These health care providers have a contract with us.Īs part of the contract, they provide services to our members at a certain rate. It includes doctors, specialists, dentists, hospitals, surgical centers and other facilities. We’re here to help you understand.Ī network is a group of health care providers. 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.
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