ACA Basic High Deductible Plan - Group ID: W0051428, Plan ID: PPOX0007
Basics
Full-Time Employee * Contribution Per Pay Period
Employee Only: $24.26
Employee & Spouse/Partner: $175.32
Employee & Children: $150.29
Employee & Family: $242.10
Employee & Spouse/Partner: $175.32
Employee & Children: $150.29
Employee & Family: $242.10
Part-Time Employee * Contribution Per Pay Period
Employee Only: $165.45
Employee & Spouse/Partner: $409.63
Employee & Children: $351.12
Employee & Family: $565.67
Employee & Spouse/Partner: $409.63
Employee & Children: $351.12
Employee & Family: $565.67
Lifetime maximum
No maximum
Plan Year
2022
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.
PENALTY for not pre-authorizing: benefit may be denied in full for failure to pre-authorize.
Offered To
Employees
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.
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.
Body/Description
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.
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
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
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.
$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.)
$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
Non-Network: 50% after deductible
Maternity Hospital Stay
Network: 60% after deductible
Non-Network: 50% after deductible
Non-Network: 50% after deductible
Baby's First Exam
Network: 60% after deductible
Non-Network: 50% after deductible
Non-Network: 50% after deductible
Birthing Centers
Network: 60% after deductible
Non-Network: 50% after deductible
Non-Network: 50% after deductible
Midwives
Network: 60% after deductible
Non-Network: 50% after deductible
Non-Network: 50% after deductible
Prenatal Visits
Network: 60% after deductible
Non-Network: 60% after deductible
Non-Network: 60% 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.
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 CARE
[no visit limit]
Network: 60% after deductible.
Non-Network: 50% of the allowed amount after deductible
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
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
Acupuncture
Network: 60% after deductible
Non-Network: 50% after deductible
Up to 20 combined Network and Non-Network visits per year
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
Non-Network: 50% after deductible
Allergy Treatment
Network: 60% after deductible
Non-Network: 50% 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
Network: 60% after deductible
Non-Network: 50% 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
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.
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
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
Non-Network: Not covered
Hearing aids not covered
Home Health Care
Network: 60% after deductible
Non-Network: 50% after deductible
Non-Network: 50% after deductible
Hospice Care
Network: 60% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Hospital Stay
Pre-Certification required by you or your provider.
Network: 60% after deductible
Non-Network: 50% after deductible
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: Covered under Medical Lifetime Maximum on Drugs $5000
*Artificial insemination and ovulation induction are covered regardless of partner status and without a diagnosis of infertility.
Non-Network: Not covered
In Vitro, GIFT, and ZIFT: Not covered
Fertility drugs: Covered under Medical Lifetime Maximum on Drugs $5000
*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
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
Network: 60% after deductible
Non-Network: 50% after deductible
Durable Medical Equipment
Network: 60% after deductible
Non-Network: 50% after deductible
Non-Network: 50% after deductible
Occupational Therapy
Network: 60% after deductible
Non-Network: 50% 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.
Non-Network: 50% after deductible (pre-certification required)
Up to a 120-day annual maximum Network and Non-Network combined.
Physical Therapy
Network or Non-Network: Covered at 60% after deductible. (90-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.
*Note per federal regulations certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required.
Surgery : Physician Services
Network: 60% after deductible
Non-Network: 50% 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 $4,000, the plan will pay 50% of {the lesser of $4,000 or the allowed charge} = 50% x $4,000 = $2,000.
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 $4,000, 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)
Non-Network: 50% after deductible (pre-certification required)
Tubal Ligation
Network: 60% after deductible
Non-Network: 50% after deductible
Non-Network: 50% after deductible
Vasectomy
Network: 60% after deductible
Non-Network: 50% after deductible
Non-Network: 50% after deductible
X-rays
Network: 60% after deductible
Non-Network: 50% after deductible
Non-Network: 50% after deductible
Pharmacy (Retail)
Network or Non-Network: 60% after deductible
*Note per federal regulations certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required
Fertility drugs: covered at 50% after deductible; max benefit of $5,000 per lifetime
*Note per federal regulations certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required
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.
*Note per federal regulations certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required
Must use Blue Shield mail-order service
*Note per federal regulations certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required
Must use Blue Shield mail-order service
Birth Control Pills
Included in Prescription Drug benefit
Physical exams for adults
Network: 100%
Non-Network: Not covered
Non-Network: Not covered
Physical exams for children
Network: 100%
Non-Network: Not covered
Non-Network: Not covered
Pap smears
Network: 100% if part of annual preventive
Non-Network: Not covered
Non-Network: Not covered
Mammograms
Network: 100% if part of annual preventive
Non-Network: Not covered
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
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
Non-Network: Not covered
Well-woman visits
Network: 100%
Non-Network: Not covered
Non-Network: Not covered
Vision care
Network: 100%
Non-Network: Not covered
Limited to screen and refraction exams only
Non-Network: Not covered
Limited to screen and refraction exams only