How Aetna pays out-of-network benefits:

We negotiate rates with doctors, dentists and other health care providers to help you save money. We refer to these providers as being "in our network."

Some of our plans pay for services from doctors who are not in our network. Many of those plans pay for out-of-network services based on what is called the “reasonable,” “usual and customary” or “prevailing” charge. Here is how we figure out that charge.

Step 1: We review the data

We get information from Ingenix, which is owned by United HealthCare. Health plans send Ingenix copies of claims for services they received from doctors. The claims include the date and place of the service, the procedure code, and the doctor's charge. Ingenix combines this information into databases that show how much doctors charge for most services in any zip code.

Example: Doctors' charges for removing an appendix are grouped into percent ranges from low to high. The higher charges are grouped into the higher ranges. Charges that fall in the middle are grouped in the 50th range. Here is an illustration of the percent range chart for appendix removal in one zip code:

Step 2: We calculate the portion we pay

For most of our health plans, we use the 80th percent range to decide how much to pay for out-of-network services. When we make a payment at the 80th percent range, it means that 80 percent of charges in the database are the same or less for that service in a particular zip code.

Sometimes, there may not be enough charges (less than 9) in the databases for a service in a certain zip code. In this case, we may use “derived charge data” instead. “Derived charge data” is based on the charges for similar procedures, multiplied by a factor for the complexity of each procedure. We also use derived charge data for our student health plans and Aetna Affordable Health Choices® plans.

Step 3: We refer to your health plan

We pay our portion of the prevailing charge as listed in your health plan. You pay your portion (called “coinsurance”) and any deductible.

Sometimes what we pay is less than what your doctor charges. In that case, your doctor may want you to pay the difference. This is true even if you have already reached your plan’s out-of-pocket maximum.

Example: You use a doctor who is not in Aetna’s network. The doctor charges $120 for a service. The doctor sends the claim to Aetna. Your plan covers 70 percent of the “prevailing” charge. For this example, the prevailing charge is $100. And we'll assume that you have already met your deductible. Aetna would pay $70. You would pay the other $30. Your doctor may bill you for the $20 difference between the prevailing charge ($100) and the billed charge ($120). In this case, your doctor could bill you for $50.

We may use other factors to decide what to pay if a service is unusual or not performed often in your area. These factors can include:

• The complexity of the service
• The degree of skill needed
• The doctor’s specialty
• The prevailing charge in other areas
• Aetna’s own data

Exceptions

This general description does not apply to every case. Some plans set the prevailing charge at a different range. For some claims (such as those from hospitals and outpatient centers) we may use other information and data sources to figure out the charge. And not all our plans use Ingenix. (Medicare plans and plans that pay based on fee schedules are just some examples.)

Our claims coding and reimbursement policies may also affect what we pay for a claim. These policies will be shown on your Explanation of Benefits.

Background

The New York State Attorney General (NYAG) investigated conflicts of interest in the ownership and use of Ingenix data. Under an agreement with the NYAG, UnitedHealth Group agreed to stop using the Ingenix databases once an independent database (not owned by a health insurer) is created.

In a separate agreement with NYAG in January 2009, Aetna agreed to use this new database when it is ready. We also will work with the new database owner to create online tools to give you better information about the cost of out-of-network care.  And most important, you can ask your doctor what a service will cost and find the prevailing charge for that service.

For More Information

Please see your plan documents to learn more. Or call member services. Their phone number is on the back of your Aetna ID card.