What Aetna is and who sells it

Aetna is a health insurance company owned by CVS Health. It sells medical, dental, and vision plans to individuals, families, and employers. You can buy Aetna coverage through your job, through the federal health insurance marketplace (Healthcare.gov), through your state's marketplace if it runs its own, or directly from Aetna as a private plan.

Aetna operates in all 50 states plus Washington, D.C., though not every plan type is available everywhere. The plans you can choose from depend on where you live and how you're buying — employer plans look different from marketplace plans, which look different from plans you buy on your own.

Aetna also runs Medicare Advantage plans for people 65 and older, and Medicaid plans in states where it has contracts. This article focuses on commercial plans for working-age adults and families.

Key Takeaways

  • Aetna offers HMO, PPO, and high-deductible plans through employers, the marketplace, and directly, with coverage varying by location and plan type.
  • Your costs depend on the plan's deductible, copay amounts, coinsurance percentage, and out-of-pocket maximum — not on Aetna's name alone.
  • In-network providers cost less than out-of-network ones, and some plans require you to pick a primary care doctor or get referrals for specialists.
  • You can enroll in an Aetna marketplace plan during the annual open enrollment period (usually November through January) or if you have a may have access to life event.
  • Aetna's customer service, claims processing speed, and provider network vary by plan and region, so comparing specific plans matters more than comparing the company overall.

How Aetna plan types differ

Aetna sells three main types of commercial plans: HMO (Health Maintenance Organization), PPO (Preferred Provider Organization), and high-deductible plans paired with Health Savings Accounts (HSAs).

HMO plans require you to choose a primary care doctor and get referrals to see specialists. You pay less out of pocket, but you can only use in-network doctors except in emergencies. PPO plans let you see any doctor without a referral and cover out-of-network care at a higher cost to you. High-deductible plans have lower monthly premiums but higher deductibles — you pay more upfront before insurance kicks in, though you can save pre-tax money in an HSA.

Which type Aetna offers in your area depends on your location and whether you're buying through an employer, the marketplace, or directly. Not all three types are available everywhere.

What you pay: premiums, deductibles, and out-of-pocket limits

An Aetna plan's cost has four parts. Your premium is what you pay monthly to have coverage. Your deductible is what you pay out of pocket before the plan starts sharing costs with you. Your copay or coinsurance is what you pay when you use care — a copay is a flat dollar amount (like $30 to see a doctor), and coinsurance is a percentage of the bill (like 20%). Your out-of-pocket maximum is the most you'll pay in a year before the plan covers everything at 100%.

Aetna plans vary widely in these amounts. A low-premium HMO might have a $1,500 deductible and $30 copays, while a high-deductible plan might have a $4,000 deductible and lower copays. The specific numbers depend on which plan you choose, not on Aetna itself. You can see the exact costs for each plan before you buy.

If you buy through your employer, your employer pays part of the premium and you pay the rest through payroll deduction. If you buy through the marketplace, you may get a tax credit that lowers your premium if your income is below a certain level. If you buy directly from Aetna, you pay the full premium yourself.

In-network versus out-of-network providers

Aetna contracts with doctors, hospitals, and other providers in each region. Doctors in the contract are in-network; those outside it are out-of-network. You pay less when you use in-network providers because Aetna has negotiated lower rates with them.

If you use an out-of-network provider, you pay more — usually a higher copay, higher coinsurance, or both. Some plans cover out-of-network care only in emergencies. HMO plans typically cover out-of-network only for emergencies; PPO plans cover it but at higher cost to you.

Before you choose an Aetna plan, check whether your current doctors are in the network. Aetna's website has a provider search tool where you can enter your doctor's name or location and see which plans include them. Networks vary by plan and region, so the same doctor might be in-network for one Aetna plan and out-of-network for another.

How to enroll in an Aetna plan

The way you enroll depends on how you're buying. If your employer offers Aetna, enrollment usually happens once a year during your company's open enrollment period, which your employer will announce. You choose your plan through your employer's benefits system, and coverage starts on the date your employer sets.

If you're buying through Healthcare.gov or your state's marketplace, you can enroll during the annual open enrollment period, which runs from November 1 through January 15 each year. You can also enroll outside this window if you have a may have access to life event — losing job-based coverage, getting married, having a baby, or moving to a new state. You enroll directly on the marketplace website, and coverage typically starts on the first of the following month.

If you're buying directly from Aetna outside the marketplace, you can enroll year-round, but coverage may not start when ready. Aetna will tell you the start date when you buy.

Aetna's provider network and customer service by region

Aetna's network size and quality vary by state and region. In some areas, Aetna has contracts with most major hospitals and doctors; in others, the network is smaller. Before you buy, search for your doctors and preferred hospitals on Aetna's website to see whether they're in-network for the specific plan you're considering.

Customer service experiences also vary. Some people report fast claims processing and helpful phone support; others report delays or difficulty reaching someone. These experiences often depend on your specific plan, your region, and the type of claim. Reading recent reviews from people in your area can give you a sense of what to expect, though individual experiences vary.

If you have an Aetna plan through your employer, your employer's benefits team may also be able to help with questions. If you have a marketplace plan, you can contact Aetna directly or reach out to your state's health insurance consumer information program.

Frequently Asked Questions

Can I use my Aetna plan outside my state?

Emergency care is covered in all states. For non-emergency care, coverage depends on your plan type and whether you're using in-network or out-of-network providers. HMO plans typically cover only emergencies outside your home state. PPO plans usually cover out-of-network care at a higher cost. Check your plan documents or call Aetna before traveling.

Does Aetna cover prescription drugs?

Most Aetna plans include prescription drug coverage, but the copay or coinsurance varies by plan and by drug. Aetna maintains a formulary — a list of covered drugs — for each plan. You can search the formulary on Aetna's website to see what your copay would be for a specific medication before you buy the plan.

What if I need a specialist?

In an HMO plan, you need a referral from your primary care doctor to see a specialist, and the specialist must be in-network. In a PPO plan, you can see a specialist without a referral, though you'll pay less if they're in-network. Check your plan documents to see which type you have.

How do I file a claim with Aetna?

For in-network care, the provider usually files the claim for you — you just pay your copay or coinsurance at the visit. For out-of-network care, you may need to file the claim yourself. You can file online through Aetna's website, by mail, or by phone. Aetna will tell you how long processing takes when you file.

Can I switch to a different plan mid-year?

If you have an employer plan, you can usually change plans only during your company's open enrollment period. If you have a marketplace plan, you can change plans during the annual open enrollment period or if you have a may have access to life event. Outside these windows, you're locked into your current plan for the year.