Does Aetna Cover Out of Network Therapy? Insurance Benefits Explained

Key Takeaways

• Aetna may cover out-of-network therapy, but coverage specifics depend on your plan.
• Check your Summary of Benefits to see if therapy is covered and what costs are involved.
• Out-of-network therapy often costs more, with higher copayments and coinsurance rates.
• You can use Aetna’s online tools to find network providers and estimate costs.
• Mission Prep Healthcare works with most major insurance providers, including Aetna, to help families verify coverage and navigate the insurance process for their teen’s mental health treatment, so that they can understand their benefits before beginning treatment.

Understanding Aetna’s Out-of-Network Therapy Coverage

When you’re considering therapy, one of the first things you need to know is if Aetna covers out-of-network providers. This is important because it directly affects your out-of-pocket costs and the accessibility of the mental health services you need.

Basic Coverage Information

Most Aetna plans offer some level of mental health coverage, including therapy. However, the level of coverage can vary significantly depending on if your therapist is in-network or out-of-network. Generally, in-network services are more affordable due to pre-negotiated rates between Aetna and the provider.

For out-of-network therapy, the costs are typically higher. You might have a higher deductible to meet, and the coinsurance rates can be steeper. This means you’ll pay a larger portion of the therapy costs compared to in-network services.

Importance of Network Status

The network status of your therapist impacts how much you’ll pay for services. In-network therapists have agreed to a contracted rate with Aetna, which usually means lower costs for you. Out-of-network therapists, on the other hand, haven’t agreed to these rates, which can lead to higher charges.

Besides that, if your plan includes out-of-network benefits, Aetna might reimburse a portion of the therapy costs, but you’ll likely face higher copayments or coinsurance. Therefore, weigh the benefits and costs when deciding whether to see an in-network or out-of-network therapist.

Potential Costs for Therapy

When considering therapy costs, understand the potential financial impact of choosing an out-of-network provider. Here’s what you need to consider:

• Deductibles: These are the amounts you pay out-of-pocket before your insurance begins to cover services. Out-of-network deductibles are often higher.
• Coinsurance: After meeting your deductible, you’ll pay a percentage of the therapy costs. This rate is usually higher for out-of-network services.
• Copayments: These are fixed amounts you pay for each therapy session. Out-of-network copayments can also be higher.

How to Determine Your Aetna Plan’s Coverage

To know exactly what your Aetna plan covers for therapy, you’ll need to do a bit of homework. This involves checking your Summary of Benefits and using Aetna’s resources to clarify your coverage.

Accessing Your Summary of Benefits

Your Summary of Benefits (SOB) is a document that outlines what your Aetna plan covers, including mental health services like therapy. Here’s how you can access it:

• Log into your Aetna Member Services portal, known as “myAetna.”
• Contact Aetna’s member services directly for assistance.
• Check your employer’s benefits portal if your insurance is through your job.

Once you have your SOB, look for the “Outpatient Mental Health” line item. This section will tell you if therapy is covered and whether it includes out-of-network providers.

Using Aetna’s Online Tools

Aetna offers several online tools to help you understand your coverage:

• Provider Directory: Use Aetna’s provider search tool on their website to find in-network therapists. Filter by specialty (psychologist, psychiatrist, licensed clinical social worker) and location to find providers that accept your specific plan.
• Cost Estimator Tool: This feature helps you estimate what you might pay for therapy sessions based on your plan’s coverage, deductible status, and the provider’s contracted rate.
• Coverage Advisor: Aetna’s Coverage Advisor tool can help you understand specific mental health benefits and what authorization requirements might apply.
• Virtual Care Options: Check if your plan includes coverage for telehealth therapy sessions through Aetna’s virtual care partners.
• Benefits Verification Tool: Once logged into your account, you can verify specific coverage details for mental health services, including therapy session limits and copay/coinsurance amounts.

For the most accurate information, consider calling the member services number on the back of your Aetna ID card and specifically asking about mental health coverage details for your plan.

Aetna’s Coverage for Specific Therapy Types

In-Person vs. Online Therapy

Aetna typically covers both in-person and online therapy, but the specifics of your plan will determine the extent of coverage for each. In-person therapy involves face-to-face sessions at a therapist’s office, while online therapy, also known as teletherapy, allows you to have sessions via video calls from the comfort of your home. Verify with Aetna if your plan covers online therapy and if there are any specific requirements or limitations.

Limitations on Therapy Locations

Aetna may have restrictions on where therapy can be conducted, especially if you’re seeking out-of-network services. Some plans might only cover therapy sessions conducted within certain geographical areas or states. Therefore, if you’re considering therapy while traveling or if you live near state borders, confirm with Aetna whether these sessions will be covered.

Exclusions for Couples Therapy

Note that not all Aetna plans cover couples therapy. This type of therapy focuses on improving relationships and communication between partners, but because it doesn’t always fit the traditional medical model of individual mental health treatment, it may not be included in your coverage.

If you’re considering couples therapy, check your Summary of Benefits to see if it’s covered. If not, you may need to explore other options, such as paying out-of-pocket or seeking therapists who offer sliding scale fees based on income.

Financial Considerations for Out-of-Network Therapy

Choosing an out-of-network therapist often means higher out-of-pocket costs. Understanding these financial implications can help you make an informed decision about your mental health care. 

Calculating Out-of-Pocket Costs

When you’re seeing an out-of-network therapist, calculate your potential out-of-pocket costs. These costs can include deductibles, coinsurance, and copayments, which tend to be higher than those for in-network services. Start by checking your Summary of Benefits to see the deductible amount you need to meet before Aetna begins to cover a portion of the costs.

After meeting your deductible, you’ll likely pay a percentage of the therapy costs, known as coinsurance. This percentage can vary widely depending on your plan. Additionally, copayments, which are fixed amounts you pay per session, can also add up. Therefore, have a clear understanding of these costs before starting therapy.

Reimbursement Procedures

If your plan includes out-of-network benefits, you might be eligible for reimbursement for some of the therapy costs. However, the reimbursement process can be complex and requires careful attention to detail. Here’s a general outline of the steps involved:

• Pay the therapist’s full fee at the time of service.
• Obtain a detailed invoice or superbill from your therapist, which includes necessary information like diagnosis codes and session details.
• Submit a claim to Aetna using their specified forms and procedures.
• Wait for Aetna to process the claim and issue a reimbursement check if applicable.

Always keep copies of all documentation and correspondence with Aetna to ensure a smooth reimbursement process.

Financial Protections and Assistance Options

For those concerned about the costs of out-of-network therapy, there are several financial protections and assistance options available. Some therapists offer sliding scale fees based on your income, making therapy more affordable. Additionally, Flexible Spending Accounts (FSAs) or Health Savings Accounts (HSAs) can be used to pay for therapy expenses with pre-tax dollars.

It’s also worth exploring community mental health centers or non-profit organizations that provide low-cost or free therapy services. While these options may not always offer the same level of personalized care as private therapists, they can be a valuable resource for those in need of mental health support.

Understand Aetna Coverage with Mission Prep’s Support

Understanding Aetna’s out-of-network therapy coverage can be complex, with benefits varying widely depending on your specific plan type, deductibles, and coverage limitations. 

At Mission Prep Healthcare, we understand that navigating insurance shouldn’t be an additional burden when you’re seeking quality mental health treatment for your teen. Our dedicated admissions team works with families daily to verify Aetna benefits, explain coverage details, and help maximize your insurance benefits.

We focus on what truly matters: providing exceptional, evidence-based mental health treatment for adolescents in a supportive, home-like environment. 

Our comprehensive approach treats not just your teen but the entire family system, creating sustainable change that continues long after treatment ends.

Don’t let insurance complexity delay critical mental health care for your teen. Contact Mission Prep today to verify your insurance coverage and learn how our specialized adolescent mental health programs can help your family find the fresh start you need.

Frequently Asked Questions (FAQ)

What defines out-of-network with Aetna?

Out-of-network providers are those who do not have a contract with Aetna to provide services at pre-negotiated rates. Choosing an out-of-network provider usually means higher out-of-pocket costs, as these providers can charge their own rates, and your insurance may cover a smaller portion of the bill.

Can I appeal coverage decisions?

Yes, if Aetna denies coverage for a therapy service, you have the right to appeal the decision. The appeals process involves submitting a formal request for reconsideration, often with supporting documentation from your therapist. Contact Aetna for specific instructions on how to proceed with an appeal.

What do coinsurance terms mean?

Coinsurance is the percentage of costs you pay for a covered health service after you’ve met your deductible. For example, if your plan has a 20% coinsurance rate, you’ll pay 20% of the therapy costs while Aetna covers the remaining 80%, up to the allowed amount.

Are there alternatives to out-of-network providers?

If out-of-network costs are prohibitive, consider seeking in-network therapists, as they typically offer lower costs due to negotiated rates with Aetna. Additionally, some therapists offer sliding scale fees based on income, making therapy more accessible.

How does Mission Prep work with insurance for teen mental health treatment?

Mission Prep Healthcare works with most major insurance providers, including Aetna, to help families access quality mental health treatment for their teens. Our admissions team helps verify insurance benefits before treatment begins and explains coverage details, potential out-of-pocket costs, and reimbursement processes.