Aetna Insurance Plan Guide for Texas 2024

All You Need to Know About Aetna Insurance Plans for 2024

Searching for Health insurance in Texas doesn’t have to be a burden. If you’ve spent your time looking for the best health insurance for you and your family and are still confused, you’ve come to the right place. At CoverMile, we are here to assist you in understanding what Aetna has to offer and to guide you through selecting the best insurance policy for you and your family.

Health Insurance Terms to Understand

Before we begin, let’s provide a few brief definitions behind some of the terms you will see frequently but may not completely understand. This will better aid you in selecting the best health coverage that fits your situation.

Deductible – Deductibles are the big one. They are the amount you will pay out of pocket before your insurance coverage kicks in. For 2024, Aetna has deductibles between $0 and $8390, depending on the plan you choose. Deductibles are based on the calendar year and refresh each year. They are also a primary figure that determines how much you will pay overall. The higher your deductible, the lower your premium; the lower your deductible, the higher your premium will be. The deductible is broken down into two parts:       

            Individual: This is the per-person deductible.

            Family: This is the deductible for the entire family.

You will see this explained on your Summary of Benefits, often in fraction form. For instance, $750 Individual/$1500 Family, or $750/$1500. Each family member receives their own $750 out-of-pocket benefit. Most of the time, the family deductible is double the individual. You can read more about deductibles through the link above.

Coinsurance – Coinsurance is where the insurance kicks in. It is cost sharing between you and the insurance company, usually reflected as a percentage. It is generally listed as “50% coinsurance” or just “50%”, whatever your policy’s coverage level is. This is the portion you will pay until your out-of-pocket max is reached. It refreshes each year. Understand that on a Summary of Benefits, when you see this number, it means after your deductible is met, unless otherwise specified.

Out-of-Pocket Max – All insurance policies have a failsafe. It’s called the out-of-pocket maximum. It is designed to help those with high medical expenses due to medical conditions who visits the doctor regularly. When you reach your deductible, pay through your coinsurance, then reach the out-of-pocket max specified in your policy, your insurance will pay 100 percent of medical expenses for that individual. This continues until the calendar year rolls over. This also has an individual and family stipulation, like your deductible.

Primary Care Physician – Your Primary Care Physician (PCP) is the main doctor you visit for your medical care. Aetna is an HMO, EPO, and a PPO. If you are under an HMO or EPO, you can see any doctor within your insurance company’s network. To see a specialist, if you are with an HMO, you will need a referral or risk not having your visit covered. An EPO is more lenient as you can go to a specialist without a referral as long as they are within the network.

HMOs, EPOs, PPOs – These are networks of doctors that Aetna contracts with. Each has rules regarding how you receive treatment and where you can receive it. The basics are: EPOs are the strictest; you can only use their networks, or you will not have coverage. HMOs, you can only use their networks, but you can go out of network if medically necessary and with permission. PPOs, you can go out of network, but your benefits are reduced. Aetna health insurance in Texas offers all three in some fashion. They offer PPOs for their small business clients, EPOs for their Medicare customers, and for the Marketplace, they offer HMO plans.

Copay – Copays are the amount you pay the doctor or facility for your visit. This can be a flat dollar amount or a percentage. It can vary by plan. Understand this will be for the office visit alone, not the treatment you receive. However, some treatments can be included in an office visit, like a well checkup or immunizations; see your medical plan for details.

Now that you know the basics of health insurance, let’s get into the plans Aetna offers its policyholders.

Aetna Health Insurance and the Affordable Care Act

Aetna offers plans that are included as part of the Affordable Care Act. They are broken down into two of the three medal plans: Silver and Gold. These plans are offered on the ACA Marketplace and its website. To view their full selection, you can visit the Aetna website.

In this review, we will show you a variety of plans Aetna offers. For the sake of space, we are only listing a few plans based on price, deductible, and coinsurance. Also, to simplify our table, you will see the Individual and Family deductibles and out-of-pocket maxes expressed as fractions. The first number is your Individual, and the second is your Family. Also, be aware that these numbers are for in-network doctors and facilities.

Children’s Dental and Vision

Children’s Vision insurance is included with Aetna Health Insurance plans, but you are only given the option to include children’s dental care if you purchase your plan OFF-exchange.  

Aetna Bronze

After searching their website, it does not appear that Aetna offers a Bronze metal plan for 2024 in Texas.

Aetna Silver

Aetna Silver has six health insurance plans. Silver metal policies are popular due to premium tax credits through the Affordable Care Act. You can save based on your household income and family size. Additional savings come to those eligible for Cost Sharing Reductions (CSR). Those who qualify for the premium tax credit can apply at any metal level, but with CSR may reap the greatest benefits at the Silver metal tier.

Silver	Aetna Texas Silver S: HMO	Aetna Texas Silver 1: HMO	Aetna Texas Silver 5: HMO	Aetna Texas Silver 7: HMO
Deducible	$5900/$11,800	$4400/$8800	$8395/16,790	$7795/$15950
Coinsurance	40%	40%	50%	50%
Out-of-Pocket Max	$9100/$18,200	$8550/17,100	$8885/$17,770	$8845/$17690
Primary Care Visit	$40 copay	$30 copay	$50 copay	$30
Specialist Visit	$80 copay	$60 copay	$80 copay	$60
Emergency Room	40%	40%	50%	50%
Urgent Care	$60 copay	$50 copay	$100	$50
Inpatient Hospital	40%	40%	50%	50%
Outpatient Hospital	40%	40%	50%	50%
Prescription (Pharmacy)	$20/$40/$80/ $350*	$5/$25/$55/ 40%/50%*	$5/$25/40%/ 45%/50%*	$5/$25/$55/ 45%/50%

*Prescriptions are Preferred Generic, Preferred Brand, Non-Preferred Generic/Brand, and Non-Preferred Generic/Specialty

The following plans are also Silver. They are designed for the Cost Sharing Reduction program. Aetna has 15 Silver CSR plans, broken up into five different categories, with three plans in each category. These are accessible when one qualifies for premium tax credits. They are only available through the Marketplace.

Silver CSR	Aetna Texas Silver S: HMO CSR 73	Aetna Texas Silver 1: HMO CSR 87	Aetna Texas Silver 5: HMO CSR 94
Deducible	$5700/$11,400	$1000/$2000	$0
Coinsurance	40%	30%	50%
Out-of-Pocket Max	$7200/$14,400	$2875/$5650	$1275/$2550
Primary Care Visit	$40 copay	$5 copay	$0
Specialist Visit	$80 copay	$30 copay	$15
Emergency Room	40%	30% after deductible	50%
Urgent Care	$60 copay	$20 copay	$5
Inpatient Hospital	40%	30% after deductible	50%
Outpatient Hospital	40%	30% after deductible	50%
Prescription (Pharmacy)	$20/$40/$80/$350*	$5/$15/$25/40%/50%*	$0/10%/40%/50%*

*Prescriptions are Preferred Generic, Preferred Brand, Non-Preferred Generic/Brand, and Non-Preferred Generic/Specialty

Aetna Gold

Aetna Gold has four plans, providing the highest level of coverage. Thus, it comes with the highest price tag. Gold plans are best for those who visit the doctor often or those who receive advanced medical care for a chronic medical condition.

Gold	Aetna TX Gold S: HMO	Aetna TX Gold 3: HMO	Aetna Texas Gold 4: HMO
Deducible	$1500/$3000	$795/$1590	$3500/$7000
Coinsurance	25%	50%	25%
Out-of-Pocket Max	$8700/$17,400	$9195/$18,390	$9000/$18,000
Primary Care Visit	$30 copay	$15 copay	$0 copay
Specialist Visit	$60 copay	$35 copay	$10 copay
Emergency Room	25%	50%	25%
Urgent Care	$45 copay	$25 copay	$10 copay
Inpatient Hospital	25%	50%	25%
Outpatient Hospital	25%	50%	25%
Prescription (Pharmacy)	$15/$30/$60/ $250*	$5/$15/$40/ 40%/50%*	$0/$20/30%/40%*

*Prescriptions are Preferred and Non-Preferred Generic/Preferred and Non-Preferred Brand/Preferred and Non-Preferred Specialty

Aetna: American Indians and Alaskan Native Plans 

Aetna has health plans designed for the American Indian population. They have separate price tiers. You can read about them at the following link.

Finding a Doctor or Facility in Your Network

Aetna is primarily an HMO. You are required to remain within your network of physicians and facilities. However, if it becomes medically necessary, Aetna may permit you to seek treatment outside of the network.

Aetna also provides its own network of dentists. You have the option to include it in your plan, but you will need to purchase an off-market insurance plan. Eye doctors are included in every plan.

Aetna provides a method to search for doctors and facilities near you called Smart Care. It identifies high-performing providers in your network and pairs you with them to meet your needs.

Aetna Comparison Charts:

As noted, the above are just a few available plans from each medal option. For a complete list of the Affordable Care Act plans, follow the links below.

Comparison Chart	Plan	Plan
Aetna Gold Plan	English	Spanish
Aetna Silver Plan	English	Spanish

Benefit Notices:

Keep in mind that the above is a summary of highlights only.

–The benefits reflect what a member would pay. When a non-participating provider is used, benefits are reduced.

–You are required to pay all costs up to the deductible amount before your plan begins to pay for covered services. What is shown is the per-person deductible and out-of-pocket maximum. Some deductibles do not apply for services where only copays are charged. (PCP, Specialist, Urgent care visit)

— Four prescription drug payment level tiers: Preferred and Non-Preferred Generic/Preferred and Non-Preferred Brand/Preferred and Non-Preferred Specialty

–Health Allowance: Aetna gives you $100, $25 every three months to spend on CVS Health brand wellness products. You can also receive a 20% discount on CVS Health brand products.

–Virtual Care: Zero-dollar 24/7 virtual care options to see a doctor on your schedule when you need to see one.

–Walk-in Clinic: Zero-dollar visits in some locations. MinuteClinic is available in some locations.

Prescription Coverage with Aetna

All Aetna plans under the Affordable Care Act receive prescription coverage. Each plan has varied coverage and tiers. Each has these need-to-knows.

• Step Therapy – Some drugs require step therapy before a prescribed medication is approved. Aetna will suggest a more cost-effective alternative to a brand-name prescription. If you choose not to accept the step therapy drug, you may not have coverage.
• 90-day Supply – Depending on your medication, you may be able to receive a 90-day supply to save your cost. This excludes Specialty drugs.
• Aetna Health App – Order your prescription, estimate your costs, and see alternatives.

Aetna can help you find a pharmacy in your area through its website.

At CoverMile, we help you in find the best health insurance in Texas that fits you and your family’s needs. We take the time to talk you through each plan, help you understand each Aetna plan, and assist you with signing up for Affordable Care Act insurance. Contact us today.