Skip to main content Skip to secondary navigation

2024 ACA Basic High Deductible Plan - Control #232361, Plan #004 Employee Only or Plan #005 Employee + Dependents

Basics

Full-Time Employee * Contribution Per Pay Period

Employee Only: $26.20
Employee & Spouse/Partner: $189.35
Employee & Children: $162.31
Employee & Family: $261.47

Part-Time Employee * Contribution Per Pay Period

Employee Only $197.97
Employee & Spouse/Registered Domestic Partner $481.82
Employee & Child(ren) $413.13
Employee & Family $664.84

Lifetime maximum

No overall healthcare lifetime maximum, but there is a lifetime max for fertility drugs. See below.

Plan Year

2024

Pre-Authorization Requirement

Pre-authorization 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.

Offered To

Employees

Care Management

Participation in care management is optional.

Our Aetna One Advisor 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 seamless healthcare experience.

Body/Description

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.

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

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

This document is a summary. Please refer to the plan Evidence of Coverage (EOC) for more details.

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

Office co-pay

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

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.

Benefit Type

Medical

Annual 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.)

X-rays

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

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

Prenatal and Postnatal Physician Office Visits:
Network: 100% no 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 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

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.

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

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)

CT Scans

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

Hearing Care

Network:
Preventative Exam: 100% as part of preventive care.
Non-routine Exam: 60% after deductible

Non-Network: 50% after deductible
Hearing Aids: Not covered

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)

Comprehensive Infertility Services (Artificial Insemination and Ovulation Induction): Network: 50% after deductible

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

Magnetic resonance imaging - MRI

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

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

Prosthetic & Orthotic Devices

Contact the plan for details.

Surgery : Physician Services

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

Surgery : Facility Charges

Network: 60% after deductible

Non-Network 50% of billed charges after deductible

Speech Therapy

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

Tubal Ligation

Network: 100% no 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

Pharmacy (Retail)

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

*Note per federal regulations 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.

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 regulations 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 Prescription Drug benefit

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

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

Transgender Services

Transgender Procedures subject to the applicable prior approval based upon the procedure, which may include, but 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); Trachael 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 (breast, 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.

Travel and Lodging

Contact the plan for details