Presenter name
Presenter title
Month 00, 2022
©2022 Aetna Inc.
Aetna Premier Care
Network and
Aetna Premier Care
Network Plus
Provider guide
Revised April 2022
Aetna is the brand name used for products and
services provided by one or more of the Aetna
group of companies, including Aetna Life
Insurance Company and its affiliates (Aetna).
Aetna policy statement
All Aetna presentation materials are confidential and proprietary and may
not be copied, distributed, captured, printed or transmitted (in any form)
without the written consent/authorization of Aetna, Inc..
©2022 Aetna Inc.
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Index
What is the Aetna Premier Care Network? Page 4–5
What is Aetna Premier Care Network Plus? Page 6
New for 2022 – Aetna Premier Care Network Plus Multi-Tier Page 7-8
Aetna Premier Care Network markets Page 9-10
Aetna Premier Care Network Plus markets Page 11-13
Designated specialty types Page 14
Specialist designation cycle and criteria Page 15
Tier 1 hospital designation criteria Page 16
Reciprocity Page 17-18
Frequently asked questions and answers Page 19
ID Card Sample: Aetna Premier Care Network members Page 20
ID Card Sample: Aetna Premier Care Network Plus members Page 21-22
Important resources Page 23
©2022 Aetna Inc.
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What is the Aetna Premier Care Network?
Aetna Premier Care Network is a national network. It has a concentric plan design that combines current performance networks, plus
the standard broad networks in the remaining markets.
A concentric plan design means that there are only two levels of benefits:
1.
In network/maximum savings/best for your plan: This benefit applies when a member gets care from a participating Aetna
Premier Care Network provider. We pay claims at the highest benefit level.
2. Out of network: This benefit applies to out-of-network f
acilities/physicians and non-designated physicians/hospitals. Non-
designated providers can participate in the regular broad network, but be non-participating in an Aetna Premier Care Network.
Depending on the provider’s contract, we may pay the claim at the preferred provider organization (PPO) contracted rate. The
rate will apply to the member’s out-of-network benefit, if applicable.
The Aetna Pre
mier Care Network is:
•
Built using performance networks with either 12 or 20 designated specialties that will result in the best medical cost savings in
each market
• Designed to appear as one plan with one network, the Aetna Premier Care Network
• Seen by members as Aetna Premier Care Network on their card and in the provider search tool, regardless of the networks used in
their market
• Based on where they live — members may have a broad or a narrow network, but by using the provider search tool on the
member website, they’ll only see the providers that will give them the maximum savings
©2022 Aetna Inc.
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The base medical plans available with the Aetna Premier Care Network are:
• Choice POS II (self-funded in all markets and fully insured in some markets)
• Open Access Aetna Select℠ plans (self-funded only)
There are two types of providers used for in-network benefits under the:
• Aetna Health Plan network (AHP/Broad/Direct)
•
Aetna Premier Care Network performance network
Networks are based on one of the following designation configurations:
• 12 specialties designated
• 20 specialties designated and hospitals tiered
Note: The Aetna Premier Care Network can have all types of providers (PCPs, specialists, hospitals, etc.) or only include
12 specialties or 20 specialties and hospitals. This is because in some geographies, the full network of providers is
offered (the AHP broad network). And in other geographies, there is a smaller performance network offering. The
performance networks have fewer providers in network than the full AHP network.
©2022 Aetna Inc.
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What is the Aetna Premier Care Network? (Cont)
What is Aetna Premier Care Network Plus?
The Aetna Premier Care Network Plus differs from the Aetna Premier Care Network. It can be based on an accountable care organization
(ACO) or joint venture (JV) network. When based on an ACO or JV, the Aetna Premier Care Network Plus is an exact copy of that network.
In markets where there are no ACO or JVs, the Aetna Premier Care Network Plus is built using performance networks with either 12 or 20
designated specialties. This results in the best medical cost savings in each market.
Aetna Premier Care Network Plus is a program that can be added to the Choice POS II and/or Open Access Aetna Select products. For
members to get the highest benefits, they must use providers contracted as an Aetna Premier Care Network Plus provider. This is
designated on their plan's network ID.
Aetna Premier Care Network Plus has three ways for a member to access their in-network benefits:
• ACO or JV providers
• Aetna Premier Care Network Plus performance network
• Aetna Health Plan network (AHP/Broad/Direct)
Based on the member’s home ZIP code, one of the following market configurations will apply:
• ACO or JV (e.g., Seton Health ACO, Innovation Health JV) access
• Concentric plan with in-network and out-of-network benefits (Choice POS II only)
• Concentric plan with in-network benefits only (Open Access Aetna Select only)
©2022 Aetna Inc.
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New for 2022-2023: Aetna Premier Care Network Plus Multi-Tier
Some of your patients might be in our new Aetna Premier Care Network Plus Multi-Tier program. This program is a
new national performance network offering. Multi-tiered programs sort doctors and facilities into tiers based on
their performance and ability to save money. The highest performing and most efficient doctors and facilities are in
Tier 1.
This new program introduces a multi-tier option that can be selected by a Plan Sponsor. The APCN Plus Multi-Tier
network consists of a 3 tier structure as follows:
• Tier 1 – Aetna® Premier Care Network Plus Multi-Tier providers. Utilizing a provider from this tier results in
maximum savings for Aetna members.
• Tier 2 – Aetna Health broad network providers. Utilizing a provider from this tier results in standard savings for
Aetna® members.
• Tier 3 – Out of Network providers. Utilizing a provider from this tier results in the lowest amount of savings to an
Aetna® member or no coverage at all if offered with an in-network only plan.
Please see next slide for instructions on how to identify patients who are in the APCN Plus Multi-Tier program.
©2022 Aetna Inc.
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How to identify patients who are in the APCN Plus multi-tier program
The member ID card will say “Aetna Premier Care Network Plus Multi-Tier.” (see example on slide 21)
To check your participation and tier status, visit our provider referr
al directory. If a hospital or provider doesn’t
participate with us, it will not appear in the search results.
• Tier 1 hospit
als and providers will see “maximum savings” displayed.
• Tier 2 hospitals and providers will see “standard savings”. They could see both “maximum savings” and “standard
savings’
if both a hospital and doctors are included under the same tax ID. This is referred to as having a “mixed
participation” status. This tier is our broad network of providers. It’s covered at a reduced benefits level. Most
doctors and hospitals not designated as Tier 1 but contracted with our broad network will be covered at the Tier 2
benefits level
.
• Tier 3 If a hospital or provider is out of the network, the system will display this: “We are unable to determine your
participation status . . . Services rendered by providers that are not part of the patient’s network are not covered.” A
member might still be covered for out-of-network benefits.
©2022 Aetna Inc.
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2022 Aetna Premier Care Network markets
Broad network: markets – 133
Performance networks:
Hospital/specialist markets – 26
Specialist only markets – 20
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©2022 Aetna Inc.
91.03.177.1 (2/18)
2023 Aetna Premier Care Network markets
Broad network markets
Performance networks:
Hospital/specialist markets – 27
Specialist only markets – 24
2022 Aetna Premier Care Network Plus concentric markets
Broad network: markets – 128
Performance networks:
Hospital/specialist markets – 20
Specialist-only markets – 11
ACO/Joint venture plan – 33 markets
In-network only ACO – 2 markets
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©20
2023 Aetna Premier Care Network Plus concentric markets
Broad network: markets
Performance networks:
Hospital/specialist markets – 18
Specialist-only market
s – 9
ACO/Joint venture plan – 35 markets
In-network only ACO – 1 market
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©2022 Aetna Inc.
91.03.176.1 B (6/18)
2023 Aetna Premier Care Network Plus multi-tier markets
Broad network: markets
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©2022 Aetna Inc.
Performance networks: Hospital/specialist
markets – 14
Specialist-only markets – 7
ACO/Joint venture plan – 30 markets
Designated specialty types
Markets with 12 designated specialties:
• Cardiology
• Cardiothoracic surgery
• Gastroenterology
• General surgery
• OB/GYN
• Orthopedics
• Otolaryngology
• Neurology
• Neurosurgery
• Plastic surgery
• Urology
• Vascular surgery
Markets with 20 designated specialties
include original 12 and the following 8 more:
• Allergy
• Dermatology
• Endocrinology
• Infectious disease
• Nephrology
• Ophthalmology
• Pulmonary
• Rheumatology
Please note that all other provider specialty
types will automatically “default” into Aetna
Premier Care Network or Aetna Premier
Care Network Plus (non AWH/JV) as a
preferred provider since they do not require
designation.
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©2022 Aetna Inc.
Specialist designation cycle and criteria
Market type 1
Markets with 12 specialties
based on the following
criteria:
• Case volume
• Clinical performance
• Efficiency
• Network adequacy
• Use of Tier 1 hospitals 50
pe
rcent or more of the time
• Specialists with little (less
than $1,000) or no hospital
spend
Market type 2
Markets with providers in 12
specialties already
designated via Method 1 and
8 additional specialties
based on:
• Groups that use Tier 1
hospitals 50 percent or more
of the time
• Groups that have little (less
than $1,000) or no hospital
spend
Market type 3
Markets that are not part of
Method 1 and designate 20
provider specialties based
on:
• Physicians who use Tier 1
hospitals 50 percent or more
of the time
• Groups that have little (less
than $1,000) or no hospital
spend
Note: No clinical quality or
cost‐efficiency data is used to
make selections using this
method.
- Market types 2 and 3 also require hospital tiering.
- Providers will be notified by email or letter before any change in designation
status goes into effect.
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©2022 Aetna Inc.
Tier 1 hospital designation criteria
Aetna Premier Care Network and Aetna Premier Care Network Plus may include separate tiers of network hospitals within
markets. Network hospitals are evaluated on cost-efficiency of inpatient and outpatient cases. Cost-efficiency is then
compared to the other hospitals in that market. To evaluate hospital inpatient and outpatient cost, the Aetna “medical case”
information for both acute inpatient, inpatient non-acute and outpatient procedures are used.
Medical case claims that are billed by the facility are used to evaluate hospital cost-efficiency. We don’t use place of service
categories of emergency room or outpatient procedure to determine cost-efficiency for hospitals.
What is medical case?
A medical case summarizes clinical events. It links or associates all of the claims submitted for a member during the same
treatment episode. Our Informatics case logic defines clinical events based on contiguous claims for five places of service:
1. Inpatient acute
2. Inpatient non-acute
3. Emergency room
4. Outpatient procedure facility
5. Outpatient procedure non-facility
All specialist and ancillary claims that are within the starting and ending dates of service for these cases are attached to the
case. In our analysis of hospital cost-efficiency measures, we only use claims billed for services by the facility.
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©2022 Aetna Inc.
Aetna Premier Care Network reciprocity
For a member to receive maximum savings when seeking provider services outside of their home
network (reciprocity), the following guidelines on provider selection apply:
Aetna Premier Care Network (Non-ACO)
Member type Travel to any Aetna Premier Care
Network performance network
Travel to broad network
Aetna Premier Care Network
performance network member
Aetna Premier Care Network
performance network where available
Access to broad network
Broad network home member
Access to broad network Access to broad network
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©2022 Aetna Inc.
Aetna Premier Care Network Plus reciprocity
For a member to receive maximum savings when seeking provider services outside of their home network
(reciprocity), the following guidelines on provider selection apply:
Aetna Premier Care Network Plus
Member type Travel outside home
network area but within
market*
Travel to Aetna Premier
Care Network-ACO
network
Travel to Aetna Premier
Care Network
performance network
Travel to broad network
Aetna Premier Care
Network Plus performance
network home member
Access to broad network Access to broad network Aetna Premier Care
Network performance
network where available
Access to broad network
Broad network home
member
N/A
Access to broad network Access to broad network Access to broad network
Aetna Premier Care
Network Plus-ACO
network home member
ER care: in-network
benefits/Non-ER care: out-
of-network benefits
Access to broad network Access to broad network
Note: The network reciprocity rule for Aetna Premier Care Network Plus-ACO/JV member is standard AHP networks. If a plan sponsor opts out of
any Aetna Premier Care Network Plus-ACO/JV market for an approved reason, the opt-out network is replaced with broad network.
*This applies to markets where the ACO/JV network has a more narrow service area than the AHP network in the geography. For example, the
New Jersey statewide ACO covers 19 counties but the AHP network covers 21 counties. When an Aetna Premier Care Network Plus member
leaves the 19 counties and travels into the other 2 for non-ER care, out-of-network benefits are applied.
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©2022 Aetna Inc.
Frequently asked questions and answers
Can a provider be “recommended” for designation in Aetna Premier Care Network and/or Aetna Premier Care Network
Plus from an outside source?
No. A provider can only participate in the Aetna Premier Care Network if all qualifications are met during the designation
process.
How will I know if I have been designated as an Aetna Premier Care Network/Aetna Premier Care Network Plus
participating provider?
A designation cycle is completed once every two years. All providers selected for designation will get an email/letter. It will
inform them of their new participating status. We will notify any provider who doesn’t pass the designation requirements during
a subsequent cycle.
Will all providers in a group be either designated or non-designated?
Due to multi-specialty groups, it is possible for a group to have some designated and some non-designated providers.
However, an attempt is made to keep groups whole when possible.
If providers are referring a member to another provider specialty, should the Aetna Premier Care Network/Aetna
Premier Care Network Plus status of that provider be checked?
Yes, the status of the provider the member is being referred to should be checked. This ensures they are also in network for
Aetna Premier Care Network/Aetna Premier Care Network Plus.
If an Aetna® member calls and asks if the provider is participating with Aetna, should additional information be obtained
before the provider answers?
The provider should ask for more details on the type of Aetna plan. While a provider may be participating with our broad
network, they may or may not participate in the Aetna Premier Care Network or Aetna Premier Care Network Plus performance
network.
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©2022 Aetna Inc.
ID Card Example:
Aetna Premier Care Plus Network members
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©2022 Aetna Inc.
ID Card Example:
Aetna Premier Care Network Plus Multi-Tier members
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©2022 Aetna Inc.
Important resources
• The Aetna website can be used to check a provider’s participating status for Aetna Premier Care
Network and/or Aetna Premier Care Network Plus: Aetna.com/health-care-professionals.html
• The Aetna OfficeLink Updates™ newsletter includes valuable information on Aetna Premier Care
Network and Aetna Premier Care Network Plus: Aetna.com/health-care-
professionals/newsletters-news/office-link-updates.html
• Contact the Provider Service Center with any questions: 1-888-MD-AETNA (1-888-632-3862)
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©2022 Aetna Inc.
