If you find health insurance terms confusing, you're not alone. That's why we made this handy guide. No more jargon or complicated descriptions. Just straightforward explanations about plans, payments and easy ways to save.
Covered Services
"Covered" doesn't mean free. A covered health care service is one that your plan recognizes and pays for after you've met the deductible, coinsurance or copay.
Referrals
A referral is like a permission slip from your primary care physician (PCP) to see a specialist or another provider. Many doctors can send referrals electronically.
Network Providers
Network providers participate in our network and offer special lower rates for our members, helping you save money on care.
Types of Health Plans
Knowing the differences between these common plans is your first step. This will help you feel confident about choosing the plan that's right for you. Keep in mind, your actual plan may vary from the descriptions below.
Preferred Provider Organization (PPO)
Contributions: Usually higher than HDHPs and HMOs
Deductible: Lower than HDHPs
PCP: You usually don't need to pick a PCP
Referrals: You may see any licensed doctor without a referral
Out-of-network: You're covered outside the network, but you'll usually pay more
High-Deductible Health Plan (HDHP)
Contributions: Usually lower than PPOs and HMOs
Deductible: Higher than PPOs and HMOs
PCP: Depends if plan is a PPO or HMO
Referrals: Depends if plan is a PPO or HMO
Out-of-network: You're covered outside the network, but you'll usually pay more
Paying for Care: An Overview of Terms
Understanding Your Costs
Claims are requests for your plan to pay for services you receive. We use these to check what your plan will cover and the amount we'll pay. You can find the status and amounts billed for your claim on your member website or the Aetna Health app.
Explanation of Benefits (EOB) statements show a breakdown of how we process claims. It's not a bill and may not show the current balance you owe.
Provider bills show the amount you actually owe for services. Your provider will give this to you, and you can make payments directly to them.
Cost Sharing Breakdown
Deductible: The amount you pay for out-of-pocket costs before your plan begins to pay. Each year, you pay 100% of covered expenses until you meet your deductible amount.
Coinsurance: A fixed percentage you pay after meeting your deductible. For example, if your care is $100 and your coinsurance is 20%, you pay $20.
Copay: A fixed dollar amount. For example, you may pay $25 per doctor office visit.
Out-of-pocket maximum: The maximum you pay each year for covered expenses. Once you hit your maximum, the plan pays 100% of covered expenses for the rest of the year.
In-Network vs. Out-of-Network Care
Choosing in-network providers may help save you money. These providers contract with us to offer rates that are often lower than their regular fees. They also work directly with us and send us claims for services you receive.
In Network
Cost You Less
Lower out-of-pocket costs with negotiated rates
Lower out-of-pocket costs
No balance billing
Less paperwork
Provider files your claim
Plan pays provider directly based on negotiated rate
Out of Network
Cost You More
Higher costs without contracted rates
Providers charge more for services
You may pay the difference between plan payment and provider charges
You may need to file your own claims
More paperwork to handle
01
Doctor Visit
Visit your doctor and show your Aetna member ID card. There's no need to pay at your visit unless you have a copay.
02
Claims Processing
Your doctor files your claim and the plan pays your doctor any amount it owes based on the negotiated rate.
03
Final Billing
Your doctor bills you for any amount you owe after the plan has paid their portion.
Know more, get more.
Now you know how health plans work. So you can choose confidently and use yours wisely — all year long.