In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. For example, if you have a 20 coinsurance, you pay 20 of each medical bill, and your health insurance will cover 80. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Coinsurance: Coinsurance is a percentage of a medical charge that you pay, with the rest paid by your health insurance plan, after your deductible has been met. Coinsurance: Coinsurance is a percentage of a medical charge that you pay, with the rest paid by your health insurance plan, after your deductible has been met. Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. The member's benefit plan determines coverage. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Members should discuss any matters related to their coverage or condition with their treating provider.Įach benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Treating providers are solely responsible for medical advice and treatment of members. For example, if a medical service has a 20 percent coinsurance, you would pay 20 percent of the cost and your plan would pay the other 80 percent. In 2012, 66.3 percent of private sector enrollees in employer-sponsored health insurance had plans with a co-pay for an office visit (figure 4). The percentage of costs of a covered health care service you pay (20, for example) after youve paid your deductible.

The ABA Medical Necessity Guide does not constitute medical advice. With the copay clause, you need to make a portion of payments each time you seek any medical service. The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. By clicking on “I Accept”, I acknowledge and accept that:

Copay vs coinsurance