about us > news & announcements

Health Plan to Use Aetna Network Starting June 1

The Carpenters Health and Security Plan will be serviced by an Aetna provider network for dates of service on and after June 1, 2015. (Info) Active and retired carpenters, spouses and dependents (except those on Medicare) are encouraged to select providers from the Aetna Choice POS II network. With more than 674,000 primary care doctors and specialists, it's likely that your current doctor is part of the Aetna network.

Option 1: Visit a network doctor
The health plan lets you visit any doctor, hospital or other provider otherwise covered by the plan. You are not required to use Aetna network providers, but there are definite advantages for doing so.

First, you'll save money. Network doctors contract with Aetna to offer their services at rates that are often much lower than their regular fees. You could end up paying a lot more if you use an out-of-network provider.

As part of their contract, Aetna's network providers also commit to direct billing. That is, they send their bills directly to Aetna for repricing so patients don't have to file their own claims. However, patients should expect to pay any deductibles, copayments, coinsurance or non-covered charges.

Here's another advantage of using network providers: They assume responsibility for preauthorizations, preadmission certifications, and second surgical opinions that are required by the health plan. If a provider doesn't comply and proceeds with a treatment that is not covered or medically necessary, the provider's reimbursement will be reduced, and the provider is prohibited from passing the shortfall to the patient.

Option 2: Go to a doctor outside the network
The health plan allows covered individuals to receive medical services from any licensed physician, hospital or provider covered by the plan without a referral. Just be aware of the financial implications.

Out-of-network providers may charge more than the amount the health plan will cover. Sometimes they charge a lot more. And because they are not under contract with Aetna, the health plan may or may not be able to negotiate with them. Bottom line: The health plan will not reimburse more than the "reasonable and customary" charge for the service, and the patient's responsible for the difference between the amount charged and the amount paid by the plan. (Related story)

Another downside of "going out of network" is that providers aren't responsible for preauthorizations, preadmission certifications, and second surgical opinions. These approvals (if required by the plan) are the patient's responsibility. If a required approval is not obtained and it is determined that the service was not medically necessary, no benefits will be paid. If the service is medically necessary, benefits will be paid according to the plan, without network discounts. Either way, it adds up to higher out-of-pocket costs for the patient.

Finally, there's no guarantee of direct billing when using out-of-network providers. They aren't required to send claims directly to Aetna. Patients may be asked to pay the entire bill at the time of service and file their own claim.

Is your doctor an Aetna provider?
There are clear advantages for selecting providers from the Aetna Choice POS II network. Contact your current provider's office to determine whether the provider is part of the Aetna Choice POS II network.

Aetna offers an online search tool for locating participating providers in your area. The online provider search is located on Aetna's member website, and you need to be a registered user to log on. Fortunately, registration is quick and easy, and users only have to do it once.

If you find out that your doctor is not a preferred provider and need help finding a new one, contact Carpenters Trusts and ask to speak to the Participant Advocate.

Remember to take your Aetna/Carpenters ID card to your appointments so the provider can update your insurance information. Aetna's member website allows carpenters and spouses to view and print ID cards. The site is mobile-friendly. With a smart phone or another mobile device connected to the internet, you could log on at a provider's office or facility when you need to show your card. Aetna mobile apps are also available.