Aetna’s massive hike in Out of Network Out of Pocket Maximum from 2024 to 2025

Just noticed that our Aetna POS II HDHP with HSA employer-provided insurance has had a massive hike in OOP maximum for out of network coverage.

Your benefit balances to date for 1/1/24 to 12/31/24 Family Balances Annual limit

Medical In Network Deductible* $3,200.00

Medical In Network Out of Pocket Maximum* $6,000.00

Medical Out of Network Deductible* $3,200.00

Medical Out of Network Out of Pocket Maximum* $6,000.00

This year the numbers have changed to $3,300 / $7,000 / $3,300 / $12,800

What that effectively means is that, since OON coverage is based on taking percentage of the “usual and customary” charge (which often doesn’t equal the actual full cost), and they only pay 70% of the U&C after the deductible until the OOP maximum is reached, in 2024 we would have to submit OON visits costing a total after-deductible maximum of the following, before Aetna started paying for 100% of U&C:

(6000 – 3200) / 3 x 10 = $9,333.34

Now in 2025, that figure changes to:

(12800 – 3300) / 3 x 10 = $31,666.67

This is an insane increase. How are they allowed to do that?

I’m not looking for any admonitions about how you shouldn’t use OON providers here — the very reason we chose this plan was because we do actually have several important providers who are OON and don’t have easy equivalents in network.

submitted by /u/monteverdevecchio
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