In order to make an insurance claim with Aetna Insurance, you must first understand how this company works and processes claims.
Aetna has excellent average rates for its Affordable Care Act plans, but the company also has a higher average silver plan deductible than most companies. That means you may pay higher out-of-pocket costs for those excellent premiums. It also offers both group health insurance and individual health insurance.
About Aetna Insurance
Aetna Inc. is an American-managed healthcare company that sells traditional and consumer-directed health care insurance and related services primarily through employer-paid (fully or partly) insurance and benefit programs, and through Medicare. Its services include medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans.
Since November 28, 2018, the company has been a subsidiary of CVS Health.
Aetna was founded in 1853, in Hartford, CT. Its health insurance has been named on Fortune’s World’s Most Admired Companies list and ranked No. 4 in the “Health Care: Insurance and Managed Care” category. Aetna’s health care network includes 1.2 million health care professionals, 690,000 primary care doctors and specialists, and over 5,700 hospitals.
Its health insurance serves approximately 22.1 million medical members, 12.7 million dental members, and 13.1 million pharmacy benefit management services members.
Types of health insurance from Aetna
Aetna offers both group health insurance and individual health insurance. The company’s individual health insurance plans are branded as Aetna CVS Health Affordable Care Act (ACA) plans.
Aetna also offers:
- Medicare
- Medicaid
- Dental insurance
- Vision insurance
- Supplemental insurance
Aetna offers two types of insurance plans on the health insurance marketplace:
- HMO: Patients with a health maintenance organization (HMO) plan typically only are covered for care from providers within the plan’s network. In most cases, you need a referral to see a specialist.
- EPO: Patients with an exclusive provider organization (EPO) plan are only covered if they use physicians, specialists or hospitals within the plan’s network. You typically don’t need a referral to see a specialist.
The company offers three metal tiers on the ACA marketplace: bronze, silver and gold. Insurers can offer bronze, silver, gold and platinum. Bronze plans have the lowest premiums but the highest deductibles and out-of-pocket costs. Gold plans have the highest premiums but the lowest out-of-pocket costs.
Aetna insurance plans and options
Along with employer health plans, Aetna offers individual health, Medicare and dental and vision insurance policies to consumers. But those looking for a short-term medical plan will need to find coverage through another insurance provider, as Aetna doesn’t currently sell short-term policies.
Employer health insurance
Employer health insurance is a health plan offered through your job. Businesses can purchase Aetna’s employer plans and provide them to employees. Employers can select what to include in their Aetna policies, which may include medical, dental, health, disability and life coverages. Read through your options carefully to confirm what will and will not be covered by your plan.
Individual plans
Individual plans are Affordable Care Act (ACA) policies that you can purchase through a state or federal health insurance exchange or through an Aetna website. Aetna’s ACA rates are cheaper than many competitor plans, making them a good choice for those on a budget.
Aetna currently offers ACA policies in the following states. The company plans to expand to certain California counties in 2023.
- Arizona
- Florida
- Georgia
- Missouri
- Nevada
- North Carolina
- Texas
- Virginia
Plan options and costs
Aetna offers Bronze, Silver and Gold policies in all areas where plans are sold.
Bronze plans are the cheapest options but generally have higher deductibles. They work well if you don’t expect to need much routine care but want coverage in case of a large medical expense.
Silver plans have medium-to-high monthly rates and are good for those with mid-level health needs. For those who have a low income, Silver plans offer help with other insurance costs like deductibles and copays.
Gold plans are best for people with typical healthcare needs. They usually cost more per month but have lower deductibles, which you can meet more quickly if you have regular healthcare visits.
Medicare advantage and supplement
Aetna offers Medicare Advantage and Supplement policies to people currently enrolled in Medicare parts A and B. These plans cover gaps in original Medicare (Parts A and B).
Aetna has three types of Medicare Advantage plans: PPO, HMO and HMO-POS. Overall, the company has some of the cheapest Medicare Advantage coverage on the market and offers plans in 46 states and Washington, D.C.
Dental and vision insurance
Stand-alone dental insurance is available through Aetna Dental Direct. Dental insurance covers all preventive services such as dental exams, X-rays, and fluoride treatments, so there will be no additional out-of-pocket costs for these services.
Aetna dental coverage isn’t available in every state. For example, residents of New York can’t access these plans. If this is the case in your state, we recommend looking for a different health insurer.
In other states, residents have additional purchasing options. Each plan typically has a different monthly premium, deductible, and coinsurance level.
| Aetna Dental Direct Preferred PPO | Aetna Dental Direct Core PPO | |
|---|---|---|
| Deductible | $50 individual/$150 family | $50 individual/$150 family |
| Coinsurance | Preventive: No costBasic: 20%Major: 50% | Preventive: No costBasic: 50%Major: 50% |
| Premium | Depends on insured age and number of dependents | Depends on insured age and number of dependents |
Aetna also supplies vision insurance policies. However, these plans are only offered in conjunction with employer health insurance and thus cannot be purchased on a stand-alone basis.
How to make an insurance claim with Aetna Insurance
Accessing health care when you need it is your priority ― and Aetna helps with that. The company also recognizes that it is important that you get reimbursed for money you’ve spent on healthcare services in a timely, efficient fashion. That’s where medical claims submission comes into play.
The process actually starts BEFORE you complete a claim form, so here’s what you can do to make it go smoothly.
Referrals
You’ll need to request a referral letter from your medical practitioner or specialist if you plan on submitting a claim for any of the following services:
- Chiropractic treatment
- Acupuncture treatment
- Osteopathic treatment
- Homeopathic treatment
- Podiatric treatment
- Physiotherapy (additional referral by a specialist required after 10 sessions)
Before you submit your claim
Make sure you know and have on hand the following:
- Your member ID number and contact information to put on forms and supporting documents
- Complete details such as the date and description of service and the reason for your visit
- All necessary supporting documents, including itemized bills, original receipts, certificates and X-rays
- Your preferred method for how you’d like to be reimbursed ― Electronic Fund Transfer (EFT), wire transfer or check―and in which of more than 157 currencies we offer payment
- Your bank name, account number, routing number, contact number and other information when choosing reimbursement via EFT
How to submit a claim online
Submitting a claim online is the most efficient method. After logging in to your secure member website, follow these steps:
- Click “Claims Center,” then “Submit claims”
- Complete your claim online
- Copy, scan and upload your supporting documents, including itemized bills, original receipts
- Click “submit claim” to complete the process
- After you submit your completed claim form, you will receive a notification by e-mail to confirm that it has been submitted successfully.
How to submit a claim by fax, email or traditonal mail
You can also submit a claim by traditional mail, email or secure fax. Mailing addresses and fax numbers are included on your form for your convenience. Don’t forget to make copies of everything you mail for your own records.
After logging in to your secure member website, follow these steps:
- Click “Forms,” from the navigation menu
- Download the form you need
- Complete the PDF or Word document online OR download, print and complete the form by hand
- Attach all necessary supporting documents, including itemized bills, original receipts, certificates and X-rays
How to update or check on a previous claim submission
If you need to update or check on the status of a specific claim you submitted online, simply find the claim reference number by clicking the appropriate button on the “Submit a claim” screen. Your history of claims that you submitted online is all there, complete with the reference tracking numbers.
Click “submit claim” to complete the process
Remember: Original receipts should be kept on file in case they are needed for verification purposes. We recommend you submit claims within 180 days, however, please refer to your plan documents or contact Member Services to confirm your plan’s exact requirements.
How much does Aetna Medicare Advantage cost?
Costs for Medicare Advantage plans will depend on your plan, geographic location and health needs.
Premiums
One of the costs to consider is the plan’s premium. About 7 in 10 Aetna plans in 2024 have no premium, and the company estimates that 84% of Medicare-eligible beneficiaries have access to a $0-monthly-premium Aetna Medicare Advantage plan.
Even as a Medicare Advantage user, you’ll still be responsible for paying your Medicare Part B premium, which is $164.90 per month in 2023 ($174.70 in 2024), although some plans cover part or all of this cost.
Copays, coinsurance and deductibles
Requirements for copays, coinsurance and deductibles vary depending on your plan, location and the services you use. Other out-of-pocket costs to consider include:
- Whether the plan covers any part of your monthly Medicare Part B premium.
- The plan’s yearly deductibles and any other deductibles, such as a drug deductible.
- Copayments and/or coinsurance for each visit or service. For instance, there may be a $10 copay for seeing your primary doctor and a $45 copay for seeing a specialist.
- The plan’s in-network and out-of-network out-of-pocket maximums.
- Whether your medical providers are in-network or out-of-network, or how often you may go out-of-network for care.
- Whether you require extra benefits, and whether the plan charges for them.
To get a sense of costs, use Medicare’s plan-finding tool to compare information among available plans in your area. You can select by insurance carrier to see only Aetna plans or compare across carriers. You can also shop directly from Aetna’s website by entering your ZIP code.
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