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ACA Basic High-Deductible Health Plan

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The ACA Basic High-Deductible Health Plan works the same as the Healthcare + Savings plan, 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).

View plan information and resources for the ACA Basic High-Deductible Health Plan

Plan enhancement as of Aug. 1, 2022: Coverage for travel to access medical care, including covered abortion services, when there is no in-network provider within 100 miles of a member’s home.

2023 Plan Details

BASICSBENEFIT
Overview

You may visit any doctor or hospital, but 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.
Group # PPOX0007

This plan is compatible with an individual Health Savings Account (HSA). You can set up an HSA with any financial institution that provides HSA services, or when you elect the ACA Basic HDHP during open enrollment, you can set up an account with Health Equity when you make your elections through My Benefits. Note that Stanford does not contribute to your HSA unlike those enrolled in the Healthcare + Savings plan.

Office copay

Network: 60% after deductible

Non-Network: 50% after deductible

Deductible

$3,250 per individual $6,500 per family for in-network services; $6,500 per individual $13,000 per family for out-of-network services.

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 me the individual deductible.

Out-of-Pocket Maximum

$6,500 per individual $13,000 per family for in-network services; $13,000 per individual $26,000 per family for out-of-network services.

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

PREVENTATIVE CAREBENEFIT
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%

Non-Network: Not covered; travel immunizations not covered.

Prostate Specific Antigen test - PSA

Network: 100%

Non-Network: Not covered

Well-woman visits 

Network: 100%

Non-Network: Not covered

PRESCRIPTION DRUGSBENEFIT
Pharmacy (Retail)

Network or

Non-Network: 60% after deductible

Mail order drug program

60% after deductible

Must use Blue Shield mail-order service

Birth Control PillsIncluded in Prescription Drug benefit
REPRODUCTIVE HEALTHBENEFIT
Abortion servicesAbortion services are available to enrolled members. After the deductible, 60 percent of the costs for network or 50 percent of the costs for non-network provider/facility use are covered by the plan.  If abortion services are not available within 100 miles of their home ZIP code, members can be reimbursed for the costs of travel (airfare, mileage, rental car, lodging, and meals) up to $10,000 annually.

Traveling Outside the U.S.

Benefits will be provided for covered services you receive anywhere in the world. Blue Shield has network providers outside of California and the United States. We encourage you to see Blue Shield providers to help reduce your costs, but you still have the option to see any provider to get needed care.

You can access service outside of California through the BlueCard Worldwide® Network.

If you need care while out of the country, call the toll-free BlueCard Program Access number at 800-810-2583, or call collect at 804-673-1177, 24 hours a day, seven days a week.

Before traveling abroad, call Blue Shield Customer Service at 855-599-2657 to find out what you need to make your plan work for you when you travel. For more information, visit the Blue Shield website.

In an emergency, go directly to the nearest hospital. As soon as possible, you should call Blue Shield at 800-343-1691 or call collect at 804-673-1177, 24 hours a day, seven days a week.