How an individual health plan works

We do not have contracted rates with health care providers who are out-of-network. Therefore, an out-of-network health care provider sets the rate to charge you. We do not know in advance what that rate will be.

Your health plan covers network health care providers. Out-of-network health care providers are covered under your health plan only in the case of an emergency and in cases where you are in a participating facility and have services delivered by certain types of non-participating providers whose bill is considered a surprise.

When an out-of-network provider bills you for charges other than copayments, coinsurance or the amount remaining on your deductible, it is called balance billing. Under federal law and some state laws, you may be protected from balance billing from an out-of-network health care provider for an emergency or when you receive services from an out-of-network health care provider in a participating facility.

If you have Aetna coverage, you can call Member Services at the toll-free number on your Aetna ID card to find out the method that your health plan uses to reimburse out-of-network health care providers.

A claim is a request to an insurance company for payment of health care services. If you use a network health care provider or facility, your claims will be submitted by that provider.
 

An individual with a health plan that provides out-of-network benefits, who sees an out-of-network health care provider, may need to submit the claim themself. Claims can be submitted by completing and mailing a claim form or alternative documentation to us as soon as reasonably possible. The mailing address is on the claim form.
 

Find a form
 

Instead of completing a claim form, an individual may send us:
 

• Patient name
• Types of service(s) rendered
• Dates of services
• Conditions being treated
• Member ID number
• Bill of charges from the health care provider
• Any medical documents you received from your health care provider
• Receipts for prescription drugs not covered under their health plan, including drug name, nature of illness or injury, purchase date, quantity, prescription number, charge, pharmacy name/address, strength, dose per/day, prescribing physician's name

Note: If required information is missing on the bill, the individual must write it on the bill and sign their name.
 

Please see your health plan documents for submission deadlines.
 

You can also call the customer service number on your ID card or 1-844-365-7373 (TTY: 711) to determine the specific time limit for submitting your claim.
 

Claim submission mailing address:
PO Box 981106
El Paso TX 79998

You are required to pay your premium by the scheduled due date. If you do not pay your premium on time, you will receive a grace period. A grace period is a time period when your coverage will not terminate even though you did not pay your premium.

For individual health plans:
 

• Premium payments are due in full each month.
• Partial payments are refunded.
• No exceptions are granted.

If you are enrolled in an individual health plan, and you do not pay your premium on time, you will get a 1-month grace period. During your 1-month grace period, your claims may be pended. If the total premium due is not paid by the end of the 1-month grace period, your coverage will terminate back to your last paid through date.

If you are enrolled in an individual health plan offered on the Health Insurance Marketplace and you receive an Advance Premium Tax Credit (APTC), and you do not pay your premium on time, you will get a 3-month grace period, and we will pay all claims for covered services that are submitted properly during the first month of the grace period. Your claims in months two and three of your grace period may be pended until full payment is received, if permitted by state law. If the total premium due is not paid in full by the end of the 3-month grace period, your coverage will terminate back to the last day of the first month of the grace period. Members who have received APTC and enter into the 3-month grace period will receive a 30-day reminder letter advising them of their outstanding premium due.
 

Claims pending

During a premium grace period, if a claim is pended, that means no claims will be paid until your delinquent premium is paid in full.

A retroactive denial reverses a previously paid claim. It occurs when coverage of a service, procedure, or drug is denied after the fact.

A retroactive denial can occur if premiums are not paid. For example, if your coverage lapses due to non-payment of your monthly premiums, we may not cover services provided during the unpaid time-period.

In the event that you have overpaid for your health plan coverage, you have the right to a refund.

Members with individual health plans should call the number on their bill or their member ID card to request a refund.

Medical necessity is used to describe care that is reasonable, necessary, and appropriate, based on evidence-based clinical standards of care.

We must approve some services for medical necessity before you obtain them. This is called prior authorization or precertification. Prior authorization is a process through which a health plan approves a request to access a covered benefit (such as surgery, or other medical procedure) based on a medical necessity review before the member accesses the benefit.

If a health care provider does not submit a request for prior authorization before the service or procedure is accessed, we may not cover the service or procedure.

We recommend that requests be made at least 2 weeks prior to the scheduled service or procedure. The below table offers more detail, but it may not apply to health plans in every state.

Request for prior authorization and medical necessity review

We typically decide on requests for prior authorization within 72 hours of receiving an urgent request or within 15 days for non-urgent requests. These timeframes may vary by state.

There are three types of prescription drug requirements. Exceptions can be requested for each type.

Precertification: Some drugs require precertification. This means that the health plan needs to approve the prescription before it is filled.

Your health care provider must request precertification and receive our decision before you can fill a prescription. Otherwise, we will not cover the cost of the drug.

Step therapy: Some drugs require step therapy. This means that you must try one or more other drugs before the step therapy drug is covered.

The other drugs are called prerequisite drugs. They have FDA approval and may cost less. They treat the same condition as the step therapy drug.

If you don't try the other drugs first, you may need to pay full cost for the step therapy drug.

Quantity limits: Quantity limits help your health care provider and pharmacist make sure that you use your drug correctly and safely.

We use medical guidelines and FDA-approved recommendations from drug makers to set quantity limits. The quantity limit program includes:

• Dose efficiency edits - Limits prescription coverage to one dose per day for drugs that have approval for once-daily dosing.
• Maximum daily dose - If a prescription is less than the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy.
• Quantity limits over time - Limits prescription overage to a specific number of units over a specific amount of time.

Prescription drug exceptions

Covered services are based on the drugs in your plan’s formulary (drug guide). If your request for a drug or non-formulary drug is denied, and our decision involved medical judgement, you have the right to request a medical exception.

You or your health care provider can request exceptions to these requirements. To submit a request for review by Aetna:

Call our Precertification Department at 1-855-240-0535 (TTY: 711) or fax a request to 1-877-269-9916.

You also can mail a written request to:

CVS Health
ATTN: Aetna PA
1300 E. Campbell Rd.
Richardson, TX 75081

You may be entitled to submit your case to an impartial organization outside of Aetna for review. This is called an Independent Review Organization (IRO). If our claim decision is one for which you can seek external review, it will be stated in the notice of adverse benefit determination. An IRO review may be requested by you, your representative, or your health care provider. The request can be submitted in writing to the address provided in the adverse benefit determination notice or by calling the number on your ID card. The IRO will send notification of its decision. We will stand by the IRO’s decision.

For a standard exception review that was denied, we will make our determination no later than 72 hours following receipt of the request. For an expedited exception review that was denied, we will make our determination no later than 24 hours following receipt of the request. To request an expedited review for exigent circumstances, call the number on your ID card.

An explanation of benefits (EOB) is a statement a health plan provides to a member. An EOB is not a bill. It shows the date you received services, the amount the health care provider billed, the amount the health plan covers, the amount the health plan paid, and the amount you are expected to pay the health care provider.

An EOB is provided after the health plan considers a claim.

Coordination of benefit rules are used to decide which health plan pays first for people who have more than one health plan. This helps coordinate coverage and allows claim information to be shared by the health plans.

When covered under an individual health plan, there are some states that allow us to coordinate your benefits as described above.  Other states do not allow coordination of benefits with an individual health plan.  Your health plan documents will describe the process in your state.

If you have Medicare as your other health plan, then Medicare will pay primary (before) your individual health plan.