You and the Plan share costs for covered treatment and services. You pay a fixed copayment for covered items such as a POS II network doctor's office visit and emergency room visits. For other types of care, you must satisfy an annual deductible and if applicable, an inpatient hospital deductible before the Plan starts paying. If you meet your annual out-of-pocket limit, the Plan pays 100% of most covered costs for the rest of that calendar year.
You share in the cost of most covered expenses. For some services, such as hospital stays, the coinsurance will be a percentage of the cost of the covered service once the deductible has been satisfied. For other services, such as office visits to an EMMP POS II network provider, the copayment will be a fixed amount. For outpatient prescription drugs, there is a percentage copayment.
- Fixed Copayment - A set amount you pay for covered services or treatments such as POS II doctor's office visits and hospital emergency room visits.
- Percentage Coinsurance - This is your share of the cost of certain covered services or treatments, such as retail and home delivery prescriptions. For medical expenses other than outpatient prescription drugs, once you meet your deductible, you and the Plan share covered costs until you reach your out-of-pocket limit.
Check the Benefits Summary section for each Plan´s coinsurance amounts.
The deductible is the amount of covered expenses you must pay each calendar year before the Plan begins sharing the cost. Fixed amount copayments do not apply toward this amount. Outpatient prescription drug percentage copayments are not subject to nor do they count toward the annual deductible.
An additional annual hospital deductible applies to inpatient hospital services.
There are several ways for a family to meet the deductible, including:
- Two covered members of your family each meet the individual deductible.
- One person meets the individual deductible and other members of your family have combined covered charges equaling an individual deductible.
- No one person meets the family deductible, but the combined covered charges of all members of your family equal the family deductible.
Note: A family deductible cannot be met by only one person.
Charges that do not count toward the deductible
- Charges above reasonable and customary levels.
- Charges not covered by the Plan.
- Charge of $500 for failure to pre-certify non- network hospital stays.
- POS II copayments.
- Any outpatient prescription drug percentage copayments.
- Charges for a private hospital room above the cost of the hospital's most common rate for a semiprivate room.
The deductible is applied to your claims in the order Aetna processes them, not when the provider collects the money from you. This means if you pay your deductible to one provider, it may not be applied to your annual deductible if Aetna has received and processed other claims first. Please be sure to always get an itemized bill from your provider and retain proof of your payment.
Check the Benefits Summary section for each Plan´s deductible amounts.
The annual out-of-pocket limit helps protect participants from high medical costs by increasing the reimbursement level when your payments for covered charges reach certain dollar limits. This limit is separate from the limits established for outpatient prescription drugs. In Medical POS II areas, the limit is different depending on whether you use network or non-network providers. Check the Benefits Summary section for each Plan´s Annual Out-of-Pocket Limits.
Family out-of-pocket limit
The family out-of-pocket limits work similarly, but the increased reimbursement then applies to you and all of your covered family members — not just the person who met the individual limit.
Expenses that do not count toward the out-of-pocket limit for either EMMP POS II option
- Charges above reasonable and customary limits.
- Charges not covered by the Plan.
- Charge of $500 for failure to pre-certify a non-network medical, behavioral health or substance use disorder hospital stay.
- Copayments for outpatient prescription drugs.
- Charges for a private hospital room greater than the cost of the hospital's most common rate for a semiprivate room.
No lifetime maximum
There is no maximum lifetime limit on benefits paid by the Plan with the exceptions of the $25,000 lifetime maximum on bariatric surgery for obesity.
Adjustments to billed charges
When providers submit charges for payment, there might be several factors affecting the amount that will be considered eligible for reimbursement including, but not limited to:
- Reasonable and customary limits
- Incidental charges
- No volitional control
References to these limitations may appear on your Explanation of benefits (EOB). We strongly suggest you contact Aetna Member Services for more information. A predetermination of benefits is strongly recommended before you incur any major or unusual expenses.