Aetna

This guide will help you understand how Aetna covers mental health and substance use disorder treatment so you can focus on your recovery and wellbeing.

When struggling with mental health challenges or substance use disorders, understanding your insurance coverage is crucial for accessing appropriate care without unnecessary financial burden. Aetna provides comprehensive behavioral health coverage as part of their commitment to supporting whole-person health.


Under the Affordable Care Act (ACA), all health insurance marketplace plans, including those offered by Aetna, must cover mental health and substance use disorder services as essential health benefits. This legislation ensures that mental health and substance use disorder treatments receive coverage comparable to medical and surgical benefits—a concept known as mental health parity. Mental health conditions are treated just like any other medical condition, meaning Aetna cannot deny you coverage because you have a mental health condition, and they cannot refuse to cover care for any diagnosed condition.


Aetna's approach to mental health recognizes the connection between physical and mental wellbeing. Their behavioral health programs are designed to provide resources at every stage of your mental health journey, from prevention and early intervention to treatment and recovery support.


Types of Aetna Plans and Mental Health Coverage

Aetna offers several types of health insurance plans, each with different approaches to mental health coverage:

  • HMO (Health Maintenance Organization) plans typically require you to choose a primary care physician who coordinates your care and provides referrals to specialists. For mental health services, you generally need to see providers within Aetna's behavioral health network to receive coverage.

  • PPO (Preferred Provider Organization) plans offer more flexibility, allowing you to see both in-network and out-of-network providers, though costs are usually lower when staying in-network. These plans typically don't require referrals to see specialists, including mental health providers.

  • Open-Access Plans allow you to choose your doctor without requiring a referral. These plans provide more freedom in selecting mental health providers while still offering cost savings for in-network care.

  • High-Deductible Health Plans paired with Health Savings Accounts (HSAs) have lower premiums but higher deductibles. Mental health services are covered, but you'll pay out-of-pocket until you meet your deductible.


Understanding your specific plan type is essential as it determines which providers you can see, whether you need referrals, and how much you'll pay out-of-pocket for services.


Mental Health Services Covered by Aetna

Aetna generally covers a wide range of mental health and substance use disorder services. While specific coverage details may vary by plan, commonly covered services include:


Outpatient Services

Aetna typically covers various outpatient mental health services, including individual therapy sessions with licensed providers, psychiatric evaluations and medication management, group therapy sessions, and psychological testing. Many plans also cover intensive outpatient programs (IOPs) that provide structured treatment several days per week while allowing patients to maintain their daily routines.


Inpatient Services

For more acute mental health needs, Aetna generally covers inpatient services such as hospitalization for mental health crises, residential treatment programs, partial hospitalization programs (PHPs), and detoxification and rehabilitation services for substance use disorders. These higher levels of care provide structured, supervised treatment in a controlled environment.


Additional Support Services

Aetna has expanded their behavioral health offerings to include various innovative approaches to mental health care. They offer telehealth mental health services, allowing members to connect with providers remotely through video visits. Many plans include access to the Aetna 360 Behavioral Health program, which takes a holistic approach to mental health and substance use disorders by considering physical health, housing, financial issues, family dynamics, and other factors that impact wellbeing.


Common Mental Health Conditions Covered

Aetna plans generally cover treatment for a wide range of mental health conditions and substance use disorders, including but not limited to:


Depression and mood disorders, anxiety disorders, post-traumatic stress disorder (PTSD), bipolar disorder, schizophrenia and other psychotic disorders, eating disorders, substance use disorders, attention-deficit/hyperactivity disorder (ADHD), and autism spectrum disorders.


Coverage for specific conditions depends on medical necessity determination. For a treatment to be covered by Aetna, it typically needs to be prescribed by your physician and be clinically proven to be effective. This means that alternative treatments that have not been properly studied may not be covered, while evidence-based treatments for diagnosed conditions generally receive coverage.


Verifying Your Aetna Mental Health Benefits

Before seeking treatment, it's important to understand your specific coverage details to avoid unexpected costs and ensure you can access the care you need. Here are steps to help you verify your benefits:

  1. Review your Summary of Benefits document: This outlines your mental health coverage, including copayments, coinsurance, deductibles, and any coverage limitations. Look for sections labeled "Mental Health and Substance Use Disorder" or "Behavioral Health Services."

  2. Use Aetna's online resources: Log in to your Aetna member account through their website or the Aetna Health app to access detailed information about your plan coverage, find in-network providers, and even manage appointments.

  3. Check provider network status: Verify if your preferred mental health provider is in-network using Aetna's online provider directory or by calling the provider directly with your insurance information. Staying in-network typically results in lower out-of-pocket costs.

  4. Understand your financial responsibility: Mental health services usually require cost-sharing in the form of:

    • Copayments: Fixed amounts paid at the time of service

    • Coinsurance: Percentage of costs you pay after meeting your deductible

    • Deductibles: Amount you pay before Aetna begins covering services


For personalized benefit information, contact Aetna Member Services by calling the number on the back of your ID card. For behavioral health needs specifically, you may be directed to Aetna Behavioral Health services for specialized assistance.


Authorization Requirements for Mental Health Treatment

Many mental health services under Aetna plans require prior authorization, especially for higher levels of care. Understanding these requirements can help avoid coverage denials and unnecessary expenses.


Services That Typically Require Prior Authorization

Aetna typically requires prior authorization (also called precertification) for inpatient hospitalization, residential treatment programs, partial hospitalization programs (PHPs), and intensive outpatient programs (IOPs). Additionally, certain specialized treatments or extended therapy beyond plan-allowed sessions may also need authorization before services begin.


For emergency mental health admissions, the facility typically must notify Aetna within a certain timeframe after admission. For non-emergency services requiring authorization, the request should generally be submitted before service delivery.


Authorization Process

The authorization process involves several steps:

  1. Initial assessment: A qualified provider evaluates your condition and recommends appropriate treatment.

  2. Provider submission: For services requiring authorization, your provider submits clinical information to Aetna justifying the medical necessity of requested services.

  3. Review and determination: Aetna reviews the information and makes a coverage decision based on medical necessity criteria. This may involve multiple levels of review, starting with clinical support staff and potentially involving licensed clinicians and physicians for more complex cases.

  4. Ongoing review: For continuing services like inpatient care, Aetna may conduct concurrent reviews to assess continued need for the level of care.


In-network providers typically handle the authorization process for you, submitting required clinical information to Aetna to justify the medical necessity of requested services. For out-of-network providers (if your plan includes out-of-network coverage), you may need to secure authorization yourself by contacting Aetna's Prior Authorization department.


Failure to obtain required authorizations can result in denied claims, so it's essential to verify requirements before beginning treatment.


Finding Aetna In-Network Mental Health Providers

Staying in-network typically results in lower out-of-pocket costs and smoother insurance processing. Finding quality providers who accept your Aetna plan is crucial for accessing affordable mental health care.


Aetna's online provider directory allows you to search specifically for behavioral health providers in your area who accept your plan. This tool makes it easy to find in-network psychiatrists, psychologists, therapists, and other mental health professionals.


For personalized assistance, you can call the Member Services number on your Aetna ID card. Representatives can help you find providers based on your specific needs, location, and plan coverage.


Our treatment directory offers a comprehensive selection of quality mental health and addiction treatment providers who accept Aetna insurance. These facilities have been vetted for their expertise in treating various mental health conditions and substance use disorders, ensuring you receive effective care from experienced professionals. Using our directory simplifies the process of finding appropriate care that's covered by your Aetna plan.


When searching for providers, consider factors beyond network status, such as experience with your specific condition, availability of appointment times, treatment approaches and specialties, and location accessibility.


Managing Out-of-Pocket Costs for Mental Health Care

Even with insurance coverage, you may have financial responsibility for some mental health treatment costs. Understanding and planning for these expenses can help make treatment more accessible.


Typical Out-of-Pocket Expenses

When using your Aetna coverage for mental health services, your costs will depend on your specific plan, but typically include:

  • Copayments: Fixed amounts (often $15-$50 for in-network therapy sessions) paid at the time of service

  • Coinsurance: Percentage of costs (like 20%) you pay after meeting your deductible

  • Deductibles: Amount you pay before Aetna begins covering services

  • Out-of-network charges: Higher costs when seeing providers outside your plan's network


Cost Management Strategies

To manage your mental health care costs effectively:

  • Stay in-network whenever possible, as Aetna has negotiated lower rates with these providers

  • Understand your deductible and plan accordingly for out-of-pocket expenses until it's met

  • Consider telehealth options, which may have lower copays than in-person appointments

  • Verify coverage details before starting treatment to avoid surprise bills

  • Look into employee assistance programs (EAPs) if available through your employer, which may offer initial counseling sessions at no cost


If you're concerned about costs, ask your provider about sliding scale fees or payment plans. Some providers offer reduced rates based on financial need, which can make treatment more affordable even if you've exhausted your insurance benefits.


Unique Features of Aetna Mental Health Coverage

Aetna 360 Behavioral Health Program

A distinctive aspect of Aetna's approach to mental health is their Aetna 360 Behavioral Health program. This comprehensive program addresses mental health and substance use problems from a holistic perspective, taking into account physical and mental health, housing and financial issues, family and relationship dynamics, and substance use disorders. The program connects members with treatment services and provides personalized care advocacy through Aetna Care Advocates who help create goals and treatment plans tailored to individual needs. This integrated approach recognizes that mental health challenges often exist alongside other life difficulties and provides comprehensive support for recovery.


Mental Health Parity Commitment

Aetna places a strong emphasis on mental health parity, ensuring that mental health and substance use disorder treatments are covered as favorably as medical treatments. This commitment means Aetna maintains similar requirements for things like prior authorization, treatment limitations, and cost-sharing across both physical and mental health services. Members who believe their plan isn't providing parity between mental health and medical services have the right to file an appeal or grievance. This dedication to parity helps reduce barriers to accessing mental health care, ensuring members can get the treatment they need without facing discriminatory coverage limitations.


How to Determine if Your Specific Aetna Plan Covers Needed Treatment

Mental health coverage can vary significantly between different Aetna plans. To determine if your specific plan covers your needed treatment, use these resources:

  • Consult your Summary of Benefits document: This outlines your specific coverage details for mental health and substance use disorder benefits, including coverage limits and cost-sharing requirements.

  • Use Aetna Navigator: This online program lets you view the details of your policy, including coverage, claims, provider information, and more.

  • Contact Aetna Member Services: Call the number on your Aetna ID card for personalized information about your specific plan's mental health coverage.

  • Speak with your provider: Mental health professionals familiar with Aetna can often help interpret coverage for specific treatments and may assist with the authorization process.


Remember that coverage determination ultimately happens when claims are processed, based on your eligibility, plan terms, and the specific services provided. The best way to understand your coverage is to verify benefits before beginning treatment, especially for higher levels of care like inpatient or residential treatment.


Benefits of Choosing a Facility That Accepts Aetna

Selecting a treatment facility that accepts Aetna insurance offers several advantages:

  • Lower out-of-pocket costs: In-network facilities have negotiated rates with Aetna, resulting in lower costs for members.

  • Streamlined billing: In-network providers handle insurance claims directly with Aetna, reducing administrative burden during an already stressful time.

  • Simplified authorization process: In-network facilities are familiar with Aetna's authorization requirements and typically handle most of this process for you.

  • Coordinated care: Aetna's care management programs can work more effectively with in-network facilities to ensure comprehensive treatment.

  • Quality assurance: Facilities in Aetna's network must meet certain standards and are screened for quality of care.


Taking the Next Step in Your Mental Health Journey

Reaching out for help is a courageous first step on the path to better mental health. With Aetna coverage, you have access to a wide range of treatment options and supportive resources.


If you're not sure where to begin, our comprehensive directory of treatment providers who accept Aetna insurance can help connect you with appropriate care. These quality facilities specialize in treating various mental health conditions and substance use disorders, and they understand how to work with your insurance to maximize your benefits.


Remember that dealing with mental health challenges or substance use disorders is not something you need to face alone. With proper treatment and support, recovery and improved wellbeing are possible.


Find Treatment Centers That Accept Aetna Today

Ready to take the next step? Browse our directory of treatment facilities that accept Aetna insurance to find the right match for your needs. Our comprehensive listings include information about services offered, treatment approaches, and location details to help you make an informed decision.


Don't let insurance concerns delay your path to wellness. With the right coverage information and support, you can access the care you need to begin your recovery journey.


References

[1] https://www.aetna.com/individuals-families/mental-emotional-health.html

[2] https://www.aetna.com/services/behavioral-health.html

[3] https://www.aetna.com/health-guide/substance-use-disorder.html

[4] https://www.aetna.com/faqs-health-insurance/mental-health-parity-faqs.html