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2027 ACA Basic High-Deductible Health Plan

The ACA Basic High-Deductible Health Plan works the same as the Stanford Choice HDHP, but has higher out-of-pocket costs.

This plan option meets the minimum essential coverage requirements under the federal health care reform, Affordable Care Act (ACA).

Plan Details

Control #: 232361, Plan #4 Employee Only, Plan #5 Employee plus Dependent(s)

You may visit any doctor or hospital. You receive a higher level of benefits when you use Aetna Choice POS II providers. You are responsible for ensuring all providers are in the network.

This plan also provides access to Crossover Health Clinics for Preventive Services and Health Coaching at no cost.

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

This page provides a high-level overview of benefits. See below for the full Summary of Benefits Coverage.

Plan Information

Plan Year:

Offered To:

Employees

Full-Time Employee * Contribution Per Pay Period:

Employee Only - $34.09
Employee & Spouse/Registered Domestic Partner - $255.01
Employee & Child(ren) - $218.69
Employee & Family - $352.25

Part-Time Employee * Contribution Per Pay Period:

Employee Only - $260.80
Employee & Spouse/Registered Domestic Partner - $637.88
Employee & Child(ren) - $546.98
Employee & Family - $880.34

Basics

Pre-Authorization Requirement:

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

Pre-authorization is required for the following services: Advanced Imaging (CT, MRI, MRA, and PET); all electively scheduled inpatient hospital admissions; all elective outpatient procedures (example – endoscopic procedures, arthroscopic procedures, epidural steroid injections, etc); other procedures and services as defined on the pre-certification requirement list.

PENALTY for not pre-authorizing: the services will be considered not covered by the plan, and the member is responsible for the full amount of the service.

*Exception: When members receive care in any inpatient facility or emergency room, or in observation bed status.

Care Management:

Participation in care management is optional.

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

Deductible:

$3,500 per individual coverage/$7,000 per family coverage in-network
$7,000 per individual coverage/$14,000 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 who met the individual deductible.

Office co-pay:

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

Crossover Clinic: 60% after deductible.

Coinsurance:

Network: 100% covered for preventive care
60% after deductible for all other services, including prescriptions

Out-of-Pocket Maximum:

$7,000 per individual/$14,000 per family In-network
$14,000 per individual/$28,000 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 Benefit:

No overall healthcare lifetime maximum, but there can be for benefits that are considered non-essential like there is a lifetime max for fertility drugs. See pharmacy section.

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

Doulas:

Not covered

Prenatal and Postnatal Physician Office Visits:

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

Doctor Delivery Charge:

Covered the same as all other inpatient surgery.

Reproductive Health:

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

If services are not available within 100 miles of the member's home zip code, travel expenses (airfare, mileage, rental car, lodging, and meals) will be reimbursable after the deductible up to $10,000 per year.

Mental Health/Autism/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 Therapy Visit [no visit limit]
Network: 60% after deductible.
Non-Network: 50% of the allowed amount after deductible

Crossover Health: 60% after deductible

Substance Abuse:

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 Therapy Visit [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.

Prescription Drugs

Pharmacy (Retail):

Network or Non-Network: Covered at 60% after deductible. (30-day supply of maintenance drugs available at Retail Pharmacy)

*Note: per federal regulation,s certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required

Fertility drugs: Covered under Medical at 50% after deductible; max benefit of $10,000 per lifetime

Cost Saver provides eligible members with automatic access to GoodRx's prescription pricing that allows them to pay lower prices, when available, on generic medications. This experience is seamless. All members have to do is present their member ID card when they pick up their prescriptions at their in-network pharmacy.

Crossover Health: Pre-pack pharmacy - no cost, included as part of the visit

Mail order drug program:

60% after deductible up to a 90-day supply at CVS mail order or CVS retail pharmacies; Specialty drugs are not available via mail order.

*Note: per federal regulation,s certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required

Must use CVS mail-order service

Birth Control Pills:

Included in the 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% (Includes Covid and Flu Shots)
Non-Network: not covered

Travel immunizations are covered both in-network and out of network at no charge.

*Immunizations may have an additional consultation fee, which the member will be responsible for, based upon where the member receives care.

Prostate Specific Antigen test - PSA:

Network: 100%
Non-Network: Not covered

Well-woman visits:

Network: 100%
Non-Network: Not covered

Other Services

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)

Benefit Perks:

Contact Health Plan for details

CT and PET Scans (Complex Imaging):

**Pre-authorization required.
Network: 60% after deductible
Non-Network: 50% after deductible

Chiropractors:

Network: 60% after deductible
Crossover Clinic: 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 is limited to certain conditions only. Contact Aetna for more information.

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

Hearing Care:

Network:
Preventive Exam: 100% as part of preventive care

Non-Routine Exam: Network 60% after deductible

Non-Network: 50% after deductible

Hearing aids are covered at $3,000 per ear for 36 months

Home Health Care:

Network: 60% after deductible - 100 days per calendar year. Prior authorization required.
Non-Network: not covered

Hospice Care:

Network: 60% after deductible
Non-Network: 50% after deductible (prior authorization required)

Hospital Stay:

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

Infertility Treatment:

Standard Base Benefit: Covers the diagnosis and treatment of underlying cause. Cost share is based upon the type of service and place of service rendered (covered for in and out of network)
Artificial Insemination: Network: 50% of billed charges.

Ovulation Induction: Network: 50% of billed charges

Advanced Reproductive Technology (ART), which includes In Vitro Fertilization (IVF), Cryo-preserved embryo transfers: Covered at 50% after deductible for up to 3 cycles per lifetime. GIFT and ZIFT are not covered.

Cryopreservation of eggs, embryos, and sperm (actual service to freeze what is retrieved from the fertility preservation IVF cycle). This is limited to 3 retrievals and thawing and storage up to 3 years of eggs, embryos and sperm. This includes iatrogenic and elective fertility.

Fertility drugs: Covered at 50% after deductible; max benefit of $10,000 per lifetime. (Covers both oral and injectable fertility drugs at 50% after deductible.) Member would be responsible for any fertility drugs over the $10,000 fertility drugs lifetime maximum and that would be an additional out-of-pocket expense.

*Artificial insemination and ovulation induction are covered regardless of partner status and without a diagnosis of infertility.

Laboratory Charges:

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

Crossover Clinic: No additional cost to office visit

Magnetic Resonance Imaging (MRI) (Complex Imaging):

**Pre-authorization required
Network: 60% after deductible
Non-Network: 50% after deductible

Meals:

Not covered

Durable Medical Equipment:

Network: 60% after deductible
Non-Network: 50% after deductible
Pre-authorization may apply

Occupational Therapy:

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

Organ Transplants:

Contact Aetna for information on transplant coverage benefits.

Skilled Nursing:

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

Up to a 120-day annual maximum Network and Non-Network combined (pre-certification required).

Physical Therapy:

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

Crossover Clinic: 60% after deductible

*All physical therapy visits are subject to Aetna’s medical necessity review process at 26 visits.

Prosthetic & Orthotic Devices:

Contact the plan for details.

Speech Therapy:

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

Surgery : Facility Charges:

Network: 60% after deductible
Non-Network 50% of billed charges after deductible

Surgery : Physician Services:

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

Transgender Services:

Transgender Procedures subject to the applicable prior approval based upon the procedure, which may include, but are not limited to: clinical diagnosis, office/progress notes from provider(s), referral letter(s), and other applicable information:

Mastopexy/Breast Augmentation, Voice and communication therapy, including B60 for therapy performed by other professionals (i.e. voice coach, bodily movement coach); Tracheal shave, Suction-assisted lipoplasty of the waist, Rhinoplasty, Facial bone reduction, Face lift, Blepharoplasty, Laryngoplasty/vocal cord (voice surgery), Liposuction (contour modeling of the waist), Lipofilling (b+D63reast, body, face), Gluteal augmentation, Permanent hair remova+B60l, Subcutaneous injection of filling material, Demabrasion, Chemical peel, Excision, excessive skin, and subcutaneous tissue; abdomen, inframubilical panniculectomy; Hair implants, Hair cranial prosthesis (wigs), Liposuction to reduce fat in hips, thighs, buttocks; Male chest reconstruction, Pectoral implants, Calf implants, Geniplasty and chin augmentation; Abdominoplasty, Facial bone reconstruction, Other electrolysis or hair laser removal, Laryngoplasty/vocal cord (voice surgery), Reversal treatment, in case a member decides to reverse procedures.

No Lifetime Limit.

Transportation:

Not covered

Travel and Lodging:

Contact the plan for details.

Tubal Ligation:

Network: 100% no deductible
Non-Network: 50% after deductible

Vasectomy:

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

Vision care:

Network: 100%
Non-Network: Not covered

Limited to screen and refraction exams only. One visit per calendar year.

X-rays (Basic Imaging):

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

Plan Documents

Summary of Benefits Coverage (SBC)

An SBC is a detailed outline of what's covered and not covered under a health plan. This includes benefits, deductibles, copays, and coverage levels for a variety of commonly used medical treatments and services.

2027 ACA Basic High-Deductible Health Plan SBC

Coming Soon: Evidence of Coverage (EOC) / Summary Plan Description (SPD)

An SPD or EOC is the official plan document for each plan outlining information about eligibility, costs and cost-sharing, included and excluded services, claims process, procedures for filing grievances, complaints, and appeals. 

The 2027 EOC will be posted here when it becomes available. 

Additional Plan Resources and Services

Aetna offers a concierge program to help you maximize your benefits and guide you to the right resources. Clinical care specialists assist you in managing chronic medical conditions, answering questions, and finding the right doctors. Get started at Aetna’s website

If you are enrolled in Stanford Choice HDHP, Stanford Select Copay Health Plan, or ACA Basic HDHP, you can get primary care through Crossover Health's in-person or virtual clinics. This expanded access enables you to receive care more quickly and at a lower cost.

Crossover Health is not a replacement for your current medical plan. Rather, an enhancement to your existing plan. At Crossover, you’ll develop an ongoing relationship with an interdisciplinary care team that will address your health concerns and look at your health history, environment, and unique circumstances that affect your complete well-being.

Learn more about Crossover

The ACA Basic High-Deductible Health Plan uses the Aetna Choice Network and offers coverage for both in-network and out-of-network services.

Know where to go for care

Aetna formulary for all three plans: Aetna Standard Plan

Aetna will help you locate high-quality and cost-effective options for diagnostic services, lab draws, imaging, colonoscopies, and other services. Visit Aetna’s website to compare costs or contact Aetna A1A member services at 833-971-4583.

There may be situations at certain facilities where providers are submitting 2 claims for the same visit, one for the provider (in office) and one for the facility (outpatient hospital). The Evaluations done on the professional claim are being processed as specialist visits, and the surgical procedures on the facility claims are being treated with Outpatient Benefits. If this occurs you may contact the Aetna A1A member services team and they can review and potentially rework it so only one of the copays applies.

Effective June 15, 2024 everyone enrolled in the Stanford Select Copay Health Plan has international benefit coverage through Aetna International.  This benefit includes a $0 deductible and 100% coinsurance for all medically necessary services received outside the United States during a vacation or a short-term business trip. 

The international component of the Copay plan includes 24/7 customer service to assist you at any time while you are travelling overseas.  You can contact Aetna’s international customer service team telephonically or via the member portal:

  • AetnaInternational.com
  • +1-800-231-7729

The Aetna International member portal is linked to AetnaHealth so you will not need to create a separate User ID and Password.  Log into AetnaHealth to access an electronic version of your international medical card which can be uploaded to your cell phone (Ios and Android).

You can receive medical services anywhere around the world.  Aetna International has an expansive network of hospitals and providers where you can receive services on a cashless basis.  This means that when you receive care from a participating facility or provider, the bill for the service is sent to Aetna directly rather than you, saving you the burden of submitting the claim for reimbursement.  You will need to contact Aetna International within 3 days of any outpatient services so Aetna can establish this service for you.  Aetna International will secure this arrangement the same day for any emergency services.

You will see the network of international providers with this link.

Aetna International has an easy process if you have to submit a claim for reimbursement:

  • Log into the member portal.
  • Go to AetnaInternational.com.
  • Click on “My Claims” and select “New Claim.”
  • Complete the online form.
  • Upload a picture of your receipts.
  • Click “Submit.”

You will receive your reimbursement via a paper check of electronically deposited into your bank account.

When you’re outside the United States and have questions about any health event, you can call Aetna International and speak with a member of their care management team.  Their clinicians are available 24/7 and can help you with:

  • Finding doctors/hospitals where you are
  • Providing culturally appropriate care recommendations
  • Coordinating and supervising emergency services including evacuation (if needed)
  • Support in multiple languages
  • Getting medical devices or prescription medications

Aetna provides “Emergency Care” coverage anywhere you may experience an emergency that is life-threatening in nature. Contact Aetna to locate an approved facility for non-emergency/non-life-threatening medical services. Pre-authorization may be required for certain services. You can log into your Aetna account and download a digital ID card at MyAetnaWebsite.com. This card will be different than your Stanford Select Copay Plan card used for domestic US benefits.

Learn more about traveling outside the U.S.