PHOENIX — Parents have been left in limbo, worried about their children’s care after Phoenix Children's Hospital and health insurer Aetna were unable to reach an agreement before their contract expired on Aug 6.
This means those who have Aetna commercial plans and get medical care at PCH, will now be considered "out-of-network" and “will have to pay more if you receive care at Phoenix Children’s,” the hospital said in a statement.
Phoenix’s Children's providers, including PCH, Phoenix Children's Medical Group, Phoenix Children's Pediatrics, and Phoenix Children's Urgent Care locations will be impacted.
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“I wish they would both just you know, put on their big boy pants and work together,” said Melanie Ford, a mother of four.
Three of her children have been getting care at PCH since they were born. Her 12 and 13-year-olds, who have pacemakers because of a genetic heart problem, are covered under Aetna.
“I hate to move them, but we can’t be paying out of pocket, you know,” Ford said. “The out-of-network prices for two kids, it’s a lot financially.”
Why did the contract between Phoenix Children’s and Aetna expire?
The companies were under negotiations when their mutual contract ended on Aug. 6. While it’s unclear why no agreement has been made before the deadline, both companies issued separate statements, pointing fingers at each other.
Aetna said in part, “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 for all our members.”
The Children’s Hospital said the insurance provider has a “significant number of routine denials.”
“The contracting process can be difficult and can cause uncertainty, especially for our patient families who rely on the expert care Phoenix Children’s provides at our 40 sites of service throughout Arizona,” the hospital said.
I have Aetna, what does this mean for me?
The contract expiration will mean Aetna patients will pay more to receive care at Phoenix Children’s unless they’re able to find care at a different center that’s "in-network."
Those with coverage through Medicaid are not impacted, nor will emergency care access. Patients may continue to receive emergency care at PCH regardless of the network status with Aetna, PCH said.
In some situations, Aetna may authorize in-network benefits if alternative providers are unavailable in the service area, PCH said.
The hospital also said if patients have a doctor’s appointment or selective procedure scheduled after Aug. 7 they may qualify for "Continuity of Care" or "Transition of Care" benefits for a short period of time if a child needs ongoing treatment for a specific illness or medical condition only.
“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,” Aeta said.
When 12News asked the insurer for clarification on what the six-month time meant, the company said:
“Any member who desires to access PCH for a period of 180 days or whenever their health plan renews, whichever is less, is protected from out-of-network balance billing by PCH, and the previously contracted rates, along with Aetna’s clinical policies will be applied. However, in most cases, claims will process at the out-of-network benefit level. The member’s Benefit Plan will govern, but PCH went out of network on August 7, 2023. Aetna also has a transition of care policy, allowing members in active treatment to request to keep their PCH provider at the in-network benefit level if certain conditions are met and approved by Aetna.”
While the dilemma plays out between both companies, Ford said she is hopeful a resolution will come soon.
“I know both entities know this is important, and that there are families like ours that need this care,” the mother said. “I really hope that money doesn’t supersede the best care for the patients.”
For more information, those affected can visit this site set up by Phoenix Children’s.
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