Phoenix Children's ends agreement with Aetna: Here's what you should know

On Aug. 7, officials with Phoenix Children's announced that their agreement with a major health insurance provider has come to an end.

According to a statement released by the hospital, people may "see changes in your financial responsibility for care received at Phoenix Children’s."

Here's what you should know about the situation.

What happened?

In a statement released on Aug. 7, officials with Phoenix Children's announced that their agreement with Aetna expired on Aug. 6, and the hospital is no longer considered to be an in-network provider of Aetna.

"Phoenix Children’s is focused on reaching an agreement that allows us to continue providing the highest quality of care to our growing community as patient families deserve exceptional pediatric care close to home," read a portion of Phoenix Children's statement.

What does this mean?

Officials with Phoenix Children's said as of Aug. 7, all Phoenix Children's providers, "including Phoenix Children’s Hospital, Phoenix Children’s Medical Group, Phoenix Children’s Pediatrics and Phoenix Children’s Urgent Care locations," will be considered out-of-network providers for all patients with Aetna commercial plans.

"You will have to pay more if you receive care at Phoenix Children’s," read a portion of the statement.

Hospital officials say Aetna plans serving those with Medicaid are not impacted.

In addition, officials with Phoenix Children's said that they offer self-pay options, and people are welcome to access their services as a self-pay patient.

"Call our financial counselors to facilitate an estimate at 602-933-2000," read a portion of the statement.

What does "out-of-network" mean?

According to Aetna's website, the insurance company has a group of health care providers, including doctors, specialists, dentists, hospitals, surgical centers, and other facilities who have a contract with them.

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

Conversely, an "out-of-network" provider is a provider with no contract with an insurance company.

On Aetna's website, it is stated that out-of-network providers usually charge a rate that is higher than an Aetna plan recognizes.

"An out-of-network doctor can bill you for anything over the amount that Aetna recognizes or allows. This is called ‘balance billing.’ A network doctor has agreed not to do that," read a portion of the website.

Aetna's website also states that some plans only cover out-of-network care in an emergency, and that people who receive out-of-network care will need to take care of the approval process for certain medical procedures themselves, whereas for in-network providers, they will take care of the process, known as pre-certification.

I have Aetna, and my loved one is getting care at Phoenix Children's. What does this mean for me?

Phoenix Children's officials say people should call the number listed on the back of their insurance card to review the specific in-network or out-of-network benefits with Aetna.

As mentioned above, Aetna plans serving those with Medicaid are not impacted.

In addition, Phoenix Children's officials say people can still receive emergency care at Phoenix Children's emergency rooms, regardless of their network status with Aetna.

In addition, officials with Phoenix Children's said certain patients may be eligible to receive what they called ‘Continuity of Care’ or ‘Transition of Care’ benefits with Aetna for a short period of time, if they need "ongoing treatment for a specific illness or medical condition only."

"For questions about ongoing care or benefits coverage, please call the phone number listed on the back of your Aetna insurance card," read a portion of the website.

When will Phoenix Children's return to Aetna's network?

"At this time, it is difficult to determine how long we may be out-of-network," read a portion of Phoenix Children's statement. "We are in ongoing communication with Aetna. We recognize and value our relationship with our patients and remain open to discussions with Aetna to reach an agreement."

What are officials with Aetna saying about this?

We reached out to officials with CVS Health, which owns Aetna, for comment, and officials released a statement that reads:

"Phoenix Children’s Hospital is a valued partner in our efforts to provide our members with access to affordable, quality, convenient care that helps them achieve better health. Unfortunately, as of August 7, 2023, PCH is longer in network for Aetna. While we will continue to negotiate with Phoenix Children’s Hospital in hopes of keeping them in network, we have been unable to reach a new agreement due to their unreasonable and excessive rate increase demands, which would raise costs for our Arizona families and employers. Negotiating fair reimbursement rates is directly connected to our ability to keep costs affordable and maintain access to quality care for all our members.

Phoenix Children’s Hospital is obligated to honor the current in-network rates for 180 days following the termination or until the member’s employer coverage renews, whichever comes first. Members may also request Transition of Care benefits, which would allow them to receive care from PCH providers at in-network benefit levels for a specified time frame. Aetna Customer Service is available to support members needing to transition care to a new provider."

Why does this sound so familiar?

In early May, we reported that Phoenix Children's may stop accepting UnitedHealthcare insurance by June 1.

"Honestly, the range of emotions that ran through me when I saw that were very similar to when I first found out my kid had a tumor," said Eric Koziatek, reflecting on the moment he learned his insurance might not work in the future with Phoenix Children's. His son, Brock, was battling an inoperable cancer.

On May 31, however, officials with Phoenix Children's announced that they have reached a multi-year agreement with UnitedHealthcare.

Our top priority throughout the negotiation was ensuring these families and children have access to quality health care from the doctors and care providers they know and trust, and this agreement accomplishes that goal," read a portion of a statement issued by officials with UnitedHealthcare.

This website does not provide medical advice. The information provided above is meant to be informative, and nothing on this site should be considered as a substitute for professional medical advice, diagnosis or treatment. If you have concerns about your health, reach out to your primary care doctor or other health care providers.