As a global leader in healthcare innovations, Aetna serves over 22 million medical members around the globe. Recently acquired by CVS Health, Aetna will remain a standalone business that will continue striving to create and sustain healthier communities.
Aetna offers the following types of insurance coverage for employers to provide for their employees:
- Network only plans: These plans are generally HMO (health maintenance organization) plans, meaning that policyholders receive care from providers that are deemed “in network,” which are providers that contract with Aetna to offer discounted rates. Members will receive the bulk of their care from a primary care provider (PCP), and specialty services typically need a referral for treatment to be covered.
- Network option plans: These plans are flexible, allowing policyholders to manage their medical care through a PCP and also to visit providers and specialists that are out of their network with or without a referral. These plans are often PPO (preferred provider organization) plans or POS (point of service) plans. They can be combined with an HRA (health reimbursement account) or an HSA (health savings account).
- Indemnity plans: These plans do not have network providers, allowing members the freedom to access care from any chosen provider or specialist without referrals.
- Medicare and retiree plans: Retirees and individuals over the age of 65 may qualify for these plans. Medicare is federally supported health insurance coverage for seniors and eligible individuals.
Health insurance coverage options through Aetna will vary, depending on where a person lives and their employer. Each individual plan has its own nuances as well. Members are encouraged to contact Aetna or their employer’s HR department directly for more detailed information regarding specifics of a policy and coverage options.
Using Aetna Insurance for Substance Abuse Treatment
Depending on the type of plan a person has, there may be different rules about how to find and enroll in a substance abuse treatment program. Plans that require members to remain in network, for example, will generally only provide coverage for chosen providers. Other plans may require that policyholders see their PCP first to obtain a referral for behavioral healthcare, which is generally considered a specialty service. The PCP may need to deem substance abuse treatment “medically necessary” before authorizing care, providing Aetna with verification that services are needed.
Treatment for substance abuse and addiction may include both outpatient and inpatient programs as well as partial hospitalization programs (PHPs) and intensive outpatient programs (IOPs). Within these models, therapy, skills training, support groups, medication management, treatment for co-occurring disorders, and educational programs are often included. Each Aetna plan can differ on what services are considered covered, but the Affordable Care Act (ACA) ensures that substance abuse treatment services are covered by insurance at similar rates to other surgical and medical procedures. This is called parity.
To use Aetna insurance to pay for treatment services, after obtaining any verification or preauthorization that is needed, individuals should first check with either a representative at Aetna or with the substance abuse treatment provider prior to enrollment in a program to find out what is covered and to what extent. A copay, which is a predetermined amount that is paid at the time services are provided, may be required for office visits, for instance. Members will also often need to first meet a deductible before insurance coverage begins. After the annual deductible is met, there may also be a coinsurance amount that policyholders will need to pay out of pocket, or on their own. There is also generally a yearly maximum for out-of-pocket expenses; after this amount is reached each year, insurance will cover any additional eligible medical costs that are incurred.