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ACA Basic High Deductible Plan - Group #PPOX0007 - 2020

Ratings
National Committee For Quality Assurance (NCQA)
Up to four stars are given for each of the following criteria:
Overall Accredition Status: 
Not reported by NCQA
Access & Services: 
0
Qualified Providers: 
0
Staying Healthy: 
0
Getting Better: 
0
Living With Illness: 
0
Basics

You may visit any doctor or hospital. You receive a higher level of benefits when you use Blue Shield PPO providers. You are responsible for ensuring all providers are in the network.

When you see a Non-Network provider you are responsible for the balance of your bill that is not covered by Blue Shield. The Out-of-Pocket Maximum does not apply to the balance of the bill not covered by Blue Shield.

This plan is compatible with an individual Health Savings Account (HSA), that you establish at a financial institution of your choice.

Description: 
ACA
Full-Time Employee * Contribution Per Pay Period: 

Employee Only: $24.26
Employee & Spouse/Registered Domestic Partner: $175.32
Employee & Children: $150.29
Employee & Family: $242.10

Part-Time Employee * Contribution Per Pay Period: 

Employee Only: $178.75
Employee & Spouse/Registered Domestic Partner: $437.55
Employee & Children: $375.05
Employee & Family: $604.23

Pre-Authorization Requirement: 

Pre-authorization required for all hospital stays and certain outpatient procedures.

PENALTY for not pre-authorizing:  benefit may be denied in full for failure to pre-authorize.

Care Management: 

Participation in care management optional

Our Shield Concierge program takes a comprehensive population health approach to care management.  Our multidisciplinary team of nurses, behavioral health clinicians, health coaches, dietitians, pharmacists, and customer services representatives help members live better with illness, recover from acute conditions, and have a more seamless healthcare experience.

Program features include acute and chronic condition care management, in-home visits, biometric remote monitoring (for some conditions), in-person and online self-management workshops, virtual cognitive behavioral therapy modules, proactive outreach by a clinical team, and integration with our Engagement Point digital solution for improved engagement.

Deductible: 

$3,250 per individual coverage/$6,500 per family coverage in-network

$6,500 per individual coverage/$13,000 out-of-network.  The individual deductible will apply to each covered family member's claims.  If met, the plan would begin sharing costs for the family member that met the individual deductible.

Office co-pay: 

Network: Plan pays 60% after deductible
Non-Network: Plan pays 50% after deductible

Coinsurance: 

Network: 100% for preventive care; 60% after deductible for all other services, including prescriptions
Non-Network: 50% of allowed charges after deductible, including prescriptions

Out-of-Pocket Maximum: 

$6,500 per individual/$13,000 per family In-network
$13,000 per individual/$26,000 per family Out-of-network

A single Out-of-Pocket Maximum applies to all coverage under the plan, including medical and prescription drugs.  (This will cover prescriptions and medical expenses at 100% once the Out-of-Pocket Maximum is met.)

Overall Lifetime Maximum: 

No maximum

Maternity
Maternity Hospital Stay: 

Network: 60% after deductible
Non-Network: 50% after deductible

Baby's First Exam: 

Network: 60% after deductible
Non-Network: 50% after deductible

Birthing Centers: 

Network: 60% after deductible
Non-Network: 50% after deductible

Midwives: 

Network: 60% after deductible
Non-Network: 50% after deductible

Prenatal Visits: 

Network: 60% after deductible
Non-Network: 50% after deductible

Doctor Delivery Charge: 

Covered the same as all other inpatient surgery

Pregnancy Termination: 

Network: 60% after deductible
Non-Network: 50% after deductible

Mental Health/Substance Abuse
Mental Health: 

INPATIENT CARE
Pre-Certification is required by you or your provider.
Network: 60% after deductible
Non-Network: 50% of the allowed amount after deductible

OUTPATIENT CARE
[no visit limit]
Network: 60% after deductible.
Non-Network: 50% of the allowed amount after deductible    

Autism: 

Behavioral health treatment (BHT) consists of professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based behavior intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorders or autism. Prior authorization for BHT or ABA services is required. Plan mental health cost sharing applies.

Substance Abuse: 

Pre-certification is required by you or your provider.

INPATIENT CARE
Network: 60% after deductible
Non-Network: 50% of the allowed amount after deductible

OUTPATIENT CARE
[no visit limit]
Network: 60% after deductible
Non-Network: 50% of the allowed amount after deductible

Other Services (A-D)
Acupuncture: 

Network: 60% after deductible
Non-Network: 50% after deductible
Up to 20 combined Network and Non-Network visits per year

Allergy Tests: 

Network: 60% after deductible
Non-Network: 50% after deductible

Allergy Treatment: 

Network: 60% after deductible
Non-Network: 50% after deductible

Alternative Medicine: 

Not covered

Ambulance charges: 

Network or Non-Network: 60% after deductible (if medically approved)

CAT Scans: 

Network: 60% after deductible
Non-Network: 50% after deductible

Chiropractors: 

Network: 60% after deductible
Non-Network: 50% after deductible
Up to 20 combined Network and Non-Network visits per year

Christian Science Practitioners: 

Not covered

Cosmetic Surgery: 

Not covered

Dental Treatment: 

Coverage limited to certain conditions only. Contact Blue Shield for more information.

Other Services (E-N)
Emergency Room: 

Network: 60% after deductible
Non-Network: 60% after deductible

Lab/ancillary/professional charges paid at 60% after deductible for Network or Non-Network

Urgent Care: 

Network or Non-Network: 60% after deductible

Hearing Care: 

Exam:  Network:  100% as part of preventive care
Non-Network: Not covered

Hearing aids not covered

Home Health Care: 

Network: 60% after deductible
Non-Network: 50% after deductible

Hospice Care: 

Network: 60% after deductible
Non-Network: 50% after deductible

Hospital Stay: 

Pre-Certification required by you or your provider.
Network: 60% after deductible
Non-Network: 50% after deductible

 

Infertility Treatment: 

Network: 50% of Blue Shield allowed charges after deductible for professional and lab services; limited to three cycles of intrauterine insemination (IUI).
Non-Network: Not covered

In Vitro, GIFT, and ZIFT:  Not covered

Fertility drugs:  see Pharmacy

Laboratory Charges: 

Network: 60% after deductible
Non-Network: 50% after deductible

Magnetic resonance imaging - MRI: 

Pre-Certification required by you or your provider.
Network: 60% after deductible
Non-Network: 50% after deductible

Durable Medical Equipment: 

Network: 60% after deductible
Non-Network: 50% after deductible

Other Services (O-Z)
Occupational Therapy: 

Network: 60% after deductible
Non-Network: 50% after deductible

Organ Transplants: 

Contact Blue Shield for information on transplant coverage benefits

Skilled Nursing: 

Network: 60% after deductible
Non-Network: 50% after deductible (pre-certification required)

Up to a 120-day annual maximum Network and Non-Network combined.

Physical Therapy: 

Network: 60% after deductible
Non-Network: 50% after deductible

Surgery : Physician Services: 

Network: 60% after deductible
Non-Network: 50% after deductible

Surgery : Facility Charges: 

Network: 60% after deductible

Non-Network (non-ambulatory surgery centers): 50% of billed charges after deductible

Non-Network (ambulatory surgery centers): 50% of allowed charges after deductible up to the maximum allowed charges of $4,000 per visit

For example, if the non-network allowed charge is $4000, the plan will pay 50% of {the lesser of $4,000 or the allowed charge} = 50% x $4,000 = $2,000.

Speech Therapy: 

Network: 60% after deductible
Non-Network: 50% after deductible (pre-certification required)

Tubal Ligation: 

Network: 60% after deductible
Non-Network: 50% after deductible

Vasectomy: 

Network: 60% after deductible
Non-Network: 50% after deductible

X-rays: 

Network: 60% after deductible
Non-Network: 50% after deductible

Prescription Drugs
Pharmacy (Retail): 

Network or Non-Network: 60% after deductible

Fertility drugs:  covered at 50% after deductible; max benefit of $5,000 per lifetime

Mail order drug program: 

60% after deductible; Specialty drugs are not available via mail order.

Must use Blue Shield mail-order service

Birth Control Pills: 

Included in Prescription Drug benefit

Preventive Care
Physical exams for adults: 

Network: 100%
Non-Network: Not covered

Physical exams for children: 

Network: 100%
Non-Network: Not covered

Pap smears: 

Network: 100% if part of annual preventive
Non-Network: Not covered

Mammograms: 

Network: 100% if part of annual preventive
Non-Network: Not covered

Immunizations: 

Network: 100% if part of annual preventive
Non-Network: Not covered

Prostate Specific Antigen test - PSA: 

Network: 100%
Non-Network: Not covered

Well-woman visits: 

Network: 100%
Non-Network: Not covered

Vision care: 

Network: 100%
Non-Network: Not covered

Limited to screen and refraction exams only