How the HMO Plan Works
- Provides in-network coverage only. You’ll pay the full cost if you seek out-of-network care.
- You must select a Primary Care Physician (PCP) and use that provider each time you need care. If you need to see a specialist, a referral by your PCP is required. Search for providers in your HMO plan’s network.
- 100% coverage after copay. The HMO pays 100% after you pay a $20 copay for office visits and most services ($40 copay for specialists).
- Limitations on dependent coverage. If you have a dependent who attends college or resides outside the plan’s network service area, he or she will not have coverage under the plan except in the case of emergency or urgently needed care. If this applies to you, consider electing the EPO plan or PPO plan, which both offer in- and out-of-network coverage. This will ensure your dependent has coverage for preventive and non-emergency medical care.
Aetna HMO Plan
|Annual Deductible (Individual/Family)||$100/$200|
|Out-of-Pocket Maximum (Individual/Family)||$3,000/$9,000|
|Preventive Care||Covered in full|
|$20 copay/$40 copay|
|Urgent Care||$25 copay|
|Emergency Room||$200 copay (waived if admitted)|
|Maternity Care (Inpatient)||$100 per day for first 3 days, then covered 100% after deductible|
|Inpatient Hospital||$100 per day for first 3 days, then covered 100% after deductible|
|Outpatient Surgery||$150 copay after deductible|
Use Your HMO Plan Wisely
Here are ways to make the most of your Aetna HMO all year long.
- Track your stats. Log in to Aetna’s website to review claims, use helpful tools, and more.
- Pair it with a Healthcare Flexible Spending Account. During a separate enrollment in November, you may choose to enroll in the Healthcare Flexible Spending Account, which allows you to set aside before-tax dollars to help pay for your eligible medical, prescription, dental, and vision expenses. Keep in mind, you can only carry over up to $570 of unused money in your FSA to the next calendar year; amounts over $570 will be forfeited.
- Get a referral. Referrals are required for specialist care. In addition, you must have a written referral from your PCP to access X-rays, laboratory testing, rehabilitation facilities, and mental health care. If you seek treatment without first obtaining a written referral from your PCP (except in emergency situations), you must pay the bill yourself.