Aetna Insurance Plan Guide for Texas 2023

All You Need to Know About Aetna Insurance Plans for 2023 in Texas

Let’s face it, looking for Health insurance in Texas can become a burden. You are never sure if you’re looking in the right place to find the best insurance for you and your family. Then once you have chosen the company, now you have to pick a plan. That, too, becomes a battle. We at Cover Mile are here to assist you with understanding what Aetna has to offer you and to guide you through the process of 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. Aetna has deductibles between $0 and $7500, 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. Each family member receives their own $750 out-of-pocket benefit. You can read more about deductibles through the link above. Most of the time, the family deductible is double the individual, but this is not always the case.

Co-insurance – Co-insurance is where the insurance kicks in. It is cost sharing between you and the insurance company, usually based on a percentage, such as 70/30. The 70 is the portion the insurance pays toward your medical fees, and the 30 percent is what you pay. This, like the deductible, refreshes each year.

Out-of-Pocket Max – All insurances have a failsafe. It is called the out-of-pocket max. It is designed to help those with high medical expenses due to medical conditions who visit the doctor regularly. When you reach your deductible, pay through your co-insurance, then reach the out-of-pocket amount specified in your policy, your insurance begins to 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 are required to coordinate all treatment first through a PCP or risk being denied coverage. Even if your symptoms will require a specialist later.

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. If you go out of network, you do not have coverage. HMOs, you can only use their networks, but you can go out of network with permission. PPOs, you can go out of network, but you will have to pay more. Aetna health insurance in Texas offers all three in some fashion. They offer EPOs 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; 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 three medal plans: Bronze, 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 co-insurance. 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 given the option to include children’s dental care. This added dental benefit goes beyond what the Affordable Care Act deems as their Essential Benefit. NOTE: Some plans below will reflect the inclusion of Pediatric Dental (PD) when purchased OFF-exchange.  

Aetna Bronze

Aetna Bronze has two plans; one of them is a Marketplace plan. The other can be purchased through their website; both plans are identical, the only difference is that one is sold with Pediatric Dental (PD). This is to comply with ACA guidelines. The ON Standard, On Marketplace, already comes with Pediatric Dental as part of the 10 Essential Benefits.

Bronze	TX CVS Aetna Bronze HMO ON Standard	TX CVS Aetna Bronze HMO OFF PD Standard
Deducible	$7500/$15,000	$7500/$15,000
Co-insurance	50%	50%
Out-of-Pocket Max	$9000/$18,000	$9000/$18,000
Primary Care Visit	$50	$50
Specialist Visit	$100	$100
Emergency Room	50% co-insurance	50% co-insurance
Urgent Care	$75 copay	$75 copay
Pediatric Dental (PD)**	No Cover	0% co-insurance
Inpatient Hospital	$850/occurrence deductible, then 50%	$850/occurrence deductible, then 50%
Outpatient Hospital	$600/occurrence deductible, then 50%	$600/occurrence deductible, then 50%
Prescription (Pharmacy)	$25/$62.50/$50/ $100/$250/$500*	$25/$62.50/$50/ $100/$250/$500*

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

**Children’s Vision insurance is included with Aetna Health Insurance plans, but you are given the option to include children’s dental care. This added dental benefit goes beyond what the Affordable Care Act deems as their Essential Benefit. NOTE: Some plans below will reflect the inclusion of Pediatric Dental (PD) when purchased OFF-exchange.

Aetna Silver

Aetna Silver has ten standard plans, five of that are offered through the Marketplace. As with the bronze level, the other five are available exclusively off-exchange and through the Aetna website. Silver plans are popular due to the Affordable Care Act cost-sharing savings they qualify for. You can see the table below for more coverage options for those eligible for cost-sharing reductions. Those who qualify for the premium tax credit apply for health insurance in Texas at the Silver level.

Below we have shown only one plan with Pediatric Dental (PD), but all plans are sold with and without the dental option. The difference depends on if you purchase your plan ON the Marketplace website or OFF the Marketplace and from Aetna directly.

Silver	Aetna CVS Silver: HMO ON Standard	Aetna CVS Silver 2: HMO ON Standard	Aetna CVS Silver 4: HMO OFF PD Standard
Deducible	$5800/$11,600	$4700/$9400	$0
Co-insurance	40%	40%	50%
Out-of-Pocket Max	$8900/$17.800	$8500/17,000	$8950/$17,800
Primary Care Visit	$40 copay	$25 copay	$30 copay
Specialist Visit	$80 copay	$50 copay	$100 copay
Emergency Room	40%	40%	50%
Urgent Care	$60 copay	$50 copay	$100
Pediatric Dental (PD)**	No cover	No cover	0%
Inpatient Hospital	40%	40%	50%
Outpatient Hospital	40%	40%	50%
Prescription (Pharmacy)	$20/$40/$80/$350*	$15/$55/40%/50%*	$30/$150/50%/50%*

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

**Children’s Vision insurance is included with Aetna Health Insurance plans, but you are given the option to include children’s dental care. This added dental benefit goes beyond what the Affordable Care Act deems as their Essential Benefit. NOTE: Some plans below will reflect the inclusion of Pediatric Dental (PD) when purchased OFF-exchange.

The following plans are also Silver. But these are designed for the Cost Sharing Reduction program. Aetna has 15 Silver plans, broken up into five different levels, with three plans on each level. These are accessible when one qualifies for premium tax credits through the Marketplace website. They are only available through the Marketplace.

Silver CSR	Aetna CVS Silver: HMO CSR 73 ON Standard	Aetna CVS Silver 2: HMO CSR 87 ON Standard	Aetna CVS Silver 4: HMO CSR 94 ON Standard
Deducible	$5700/$11,400	$1000/$2000	$0
Co-insurance	40%	30%	10%
Out-of-Pocket Max	$7200/$14,400	$2800/$5600	$2000/$4000
Primary Care Visit	$30 copay	$20 copay	$0
Specialist Visit	$60 copay	$40 copay	$10
Emergency Room	40%	30% after deductible	10%
Urgent Care	$45 copay	$40 copay	$10
Pediatric Dental (PD)**	No cover	No cover	0%
Inpatient Hospital	40%	30% after deductible	10%
Outpatient Hospital	40%	30% after deductible	10%
Prescription (Pharmacy)	$20/$40/$80/$350*	$0/$25/40%/50%*	$0/$25/40%/50%*

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

**Children’s Vision insurance is included with Aetna Health Insurance plans, but you are given the option to include children’s dental care. This added dental benefit goes beyond what the Affordable Care Act deems as their Essential Benefit. NOTE: Some plans below will reflect the inclusion of Pediatric Dental (PD) when purchased OFF-exchange.

Aetna Gold

Aetna Gold has four plans, two of which are offered on the Marketplace. Gold provides 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 CVS Gold: HMO ON Standard	Aetna CVS Gold: HMO OFF PD Standard	Aetna CVS Gold: HMO ON	Aetna CVS Gold: HMO OFF PD
Deducible	$2000/$4000	$2000/$4000	$1500/$3000	$1500/$3000
Co-insurance	25%	25%	20%	20%
Out-of-Pocket Max	$8700/$17,400	$8700/$17,400	$7000/$14,000	$7000/$14,000
Primary Care Visit	$30 copay	$30 copay	$20 copay	$20 copay
Specialist Visit	$60 copay	$60 copay	$40 copay	$40 copay
Emergency Room	25%	25%	$750 copay	$750 copay
Urgent Care	$45 copay	$45 copay	$40 copay	$40 copay
Pediatric Dental (PD)**	No Cover	0% co-insurance	No Cover	0% co-insurance
Inpatient Hospital	25%	25%	20%	20%
Outpatient Hospital	25%	25%	20%	20%
Prescription (Pharmacy)	$15/$30/$60/ $250*	$15/$30/$60/ $250*	$40/40%/50%/20%*	$40/40%/50%/20%*

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

**Children’s Vision insurance is included with Aetna Health Insurance plans, but you are given the option to include children’s dental care. This added dental benefit goes beyond what the Affordable Care Act deems as their Essential Benefit. NOTE: Some plans below will reflect the inclusion of Pediatric Dental (PD) when purchased OFF-exchange.

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 an HMO, and you are required to remain within your network of physicians and facilities. However, if it becomes medically necessary, you may be granted permission to seek treatment outside of the network. This allowance is up to Aetna’s approval.

Aetna also provides its own network of dentists that you have the option to include in your 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 need.

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
Aetna Bronze 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

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

At Cover Mile, we desire to assist you in finding the health insurance in Texas that best suits you and your family. We will take the time to talk you through each plan, help you understand each Blue Cross Blue Shield of Texas plan, and help you sign up for Affordable Care Act insurance. Contact us today.