Aetna

Understanding Co-Pays, Deductibles and Coinsurance

Co-Pays

A co-pay is usually a set dollar amount that you pay out-of-pocket every time you receive certain medical services.


Listed below are the other co-pay charges for services from Aetna network providers:

 Mail-Order Prescriptions             $10 (Generic)   

                                                $20 (Brand Name)                 

Emergency Room $50
Urgent Care/Walk-in Clinic $35
Some Doctor Office Visits*        $10
Routine Physical $10
Routine OB/GYN Exam $10

Immunizations (Waived

for Children to Age 6)    

$10










 

* The co-pay usually applies to primary care physician visits but not to visits with specialists (such as allergists and surgeons), therapists, and chiropractors.

Deductible

A deductible is an annual dollar amount you have to pay for medical services each calendar year - before insurance pays any benefits. For the MPS Aetna plan, the deductible is $100 per person per year.

 

Example: If you visit a chiropractor for your first medical service of the year, at $80 per visit, you pay the entire $80 for the first visit. For the second visit, you pay $20 before the Aetna payment and your coinsurance payment are calculated on the remaining $60.



For a family, the $100 deductible applies to each individual, but when 3 family members reach their $100 deductible amount in a year, there is no deductible for other family members.

Coinsurance

Coinsurance is your payment share for a medical service, with your insurance paying the rest of the cost. The coinsurance is a percentage of the bill. For medical services from an Aetna network doctor, your share is 10%. (Out-of-network, your share is 20%).

 

Coinsurance payments are assessed after your $100 deductible is met each year.

 

There is a cap on the total amount of coinsurance you pay per person each year -- a maximum of $200 (in-network) and $500 (out-of-network).

 

Example: If you are hospitalized (in-network) in early January and your first medical bill for the year is $25,000, you pay $100 to meet your deductible. Your coinsurance payment is 10% of the remaining $24,900; however it is capped at $200 for the year. So you pay a total of $300 -- $100 deductible and $200 coinsurance. Aetna pays the rest.

 

For a family, the annual coinsurance cap applies to each individual, but when 3 family members each reach their coinsurance cap in a year, there are no coinsurance payments for other family members.

 

Out-of-Network More Costly

If you receive services out-of-network, your coinsurance payment:

  • Increases to 20% of the bill.
  • The cap increases to $500 per year for each individual.

There is a risk that the out-of-network provider will charge in excess of the usual, customary, reasonable fee. You are responsible for the excess amount.



Example: Suppose you incur a $5,000 bill for a procedure you received from an out-of-network physician, but Aetna has established a usual, customary and reasonable (UCR) fee of $4,000 for the surgery. Based on 20% of $4,000 the coinsurance amount would be $800. Because of the $500 coinsurance cap, you would pay $500, and Aetna would pay $3,500 of the $4,000 UCR amount.

 

However, you would be responsible for paying an additional $1000, the amount in excess of the usual, customary, and reasonable fee.



Tools to Learn More

DocFind is a tool on Aetna's Web site to help you find an in-network doctor. (select "Aetna Standard Plans", then "Open Choice PPO" in the search criteria.)



Clinical Policy Bulletins describe the medical necessity and benefitting criteria for hundreds of medical treatments, services and supplies available to you in the Aetna plan.

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