Legal Notices

2025 Banner|Aetna Exclusions & Limitations List

2025 Banner|Aetna Exclusions & Limitations List - Spanish

The undersigned applicant and the agent certify that the applicant has read, or had read to him, the completed application and that the applicant realizes that any false statement or misrepresentation in the application may result in the loss of coverage under the policy.

Aetna and its affiliates provide certain management services for Banner|Aetna. The CareEngine® system is a proprietary technology platform developed by ActiveHealth Management, an Aetna company. In conjunction with clinicians, the CareEngine system continuously analyzes claims and other data against evidenced-based best practices and alerts the members and their physicians about possible care gaps and other inconsistencies. Information is not a substitute for diagnosis or treatment by a physician or other health care professional.

Program Provisions

We are proud to be an Equal Opportunity and Affirmative Action employer. It is our goal to have a work force that reasonably reflects the diversity of qualified talent that is available in relevant labor markets. This commitment to Equal Opportunity/Affirmative Action governs decisions related to all aspects of employment, including recruiting, selection, development, compensation and benefits. We do not base these decisions on personal characteristics or status, such as:

• race or ethnicity
• color
• sex
• pregnancy
• national origin
• citizenship
• ancestry
• religion
• age
• disability
• military status
• veteran status
• sexual orientation
• gender identity and/or expression
• marital or family status
• genetic information

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Save money by staying in network

Maybe you’ve read that one of the best ways to save on health care costs is to “stay in network.” But you’re not sure what that means.

You’re not alone. Many people find the term confusing. We’re here to help you understand.

A network is a group of health care providers. It includes doctors, specialists, dentists, hospitals, surgical centers and other facilities. These health care providers have a contract with us.

As part of the contract, they provide services to our members at a certain contract rate. This rate is usually much lower than what they would bill if you were not a Banner|Aetna member. And they agree to accept the contract rate as full payment. You pay your coinsurance or copay along with your deductible.

Some plans do not offer any out-of-network benefits. For those plans, out-of-network care is covered only in an emergency. Otherwise, you are responsible for the full billed amount of any care you receive out of network.

The information on this page is for plans that offer both in-network and out-of-network coverage.

Why out-of-network care costs more

There may be times when you decide to visit a doctor not in the network. If you go out of network, your out-of-pocket costs are usually higher. There are many reasons you will pay more if you go outside the network. Keep reading to learn more.

The health plan pays less

Your Banner|Aetna health benefits or insurance plan may pay part of the doctor’s bill. But it pays less of the bill than it would if you got care from a network doctor.

Also, some plans cover out-of-network care only in an emergency. 

Out-of-network rates are higher

An out-of-network doctor sets the amount to charge you. It is usually higher than the amount your Banner|Aetna plan “recognizes” or “allows.”

We do not base our payments on what the out-of-network doctor bills you. We do not know in advance what the doctor will charge.

An out-of-network doctor can bill you for anything over the amount that Banner|Aetna recognizes or allows. This is called “balance billing.” A network doctor has agreed not to do that.

Cost sharing is more

What you pay when you are balance billed does not count toward your deductible. And it is not part of any cap your plan has on how much you have to pay for covered services.

Many plans have a separate out-of-network deductible. This is higher than your in-network deductible (sometimes, you have no deductible at all for care in the network). You must meet the out-of-network deductible before your plan pays any out-of-network benefits.

With most plans, your coinsurance is higher for out-of-network care. Coinsurance is the part of the covered service you pay after you reach your deductible (e.g. the plan pays 80 percent of the covered amount and you pay 20 percent coinsurance).

You’ll have more work, too

You must get authorization for some medical procedures before they are done. We call this precertification. 

Some common procedures that require precertification include non-emergency surgery, out-patient physical rehabilitation, inpatient hospice, CT scans, and MRIs.

If you go out of network, precertification means more time and more paperwork for you. If you visit an in-network doctor, that doctor will handle precertification for you.  

How we determine what to pay for out-of-network care

The plan you have determines how much you pay for out-of-network care. The exact amount depends on the:

• Method that your plan uses to set the “recognized” or “allowed” amount
• Percent of the allowed amount to be paid by the plan (like 80 percent or 60 percent)

Your plan may base the allowed amount on a rate schedule from:

• Medicare-based rates, which are determined and maintained by the government,
• “Reasonable”, “usual and customary” and “prevailing” rates, which are obtained from a database of provider billed amounts
• Other types of rate schedules

To find the method and percent, check your plan documents. Or contact us at the toll-free number on your member ID card.

See how we might calculate costs for an out-of-network office visit

You are covered for emergency care

• You are covered for emergency care. You have this coverage while you are traveling or near your home. That includes students who are away at school.
• When you need emergency care (for example, due to a heart attack or car accident), go to any doctor, walk-in clinic, urgent care center or emergency room. When you have no choice, we will pay the bill as if you got care in network. You pay your plan’s copayments, coinsurance, and deductibles for your in-network level of benefits.
• We’ll review the information when the claim comes in. If we think the situation was not urgent, we might ask you for more information and may send you a form to fill out. Please complete the form, or call Member Services to give us the information over the phone.

Below is information regarding your options should you lose your group health care coverage.

COBRA

If your employer is subject to federal COBRA, you may be eligible to continue your group health plan coverage on a temporary basis. This coverage, however, is only available when coverage is lost due to specific events. For more information, please contact your employer.

Conversion

Conversion is medical coverage for people who are no longer eligible for the group’s medical coverage due to such circumstances as:

• Loss of employment
• Loss of eligibility as a dependent

There can be no lapse in coverage from the termination date of the employer group plan to the effective date of the individual conversion plan. Individual conversion plans do not require medical underwriting. Individual conversion benefits will differ from the group benefits and will vary depending on your state of residence.

There is a limited time to apply for the conversion policy. Members must apply and pay the first premium within 31 days of termination of group coverage. To determine what conversion option and benefits are available, please contact the traditional medical conversion unit at (866) 901-2922 or the HMO medical conversion unit at (866) 565-1235.

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When you get emergency care or you’re treated by an out-of-network provider at an in-network hospital, or ambulatory surgical center or by an air ambulance provider, you are protected from surprise billing or balance billing.

Learn more about the federal No Surprises Act

How an Individual health plan works