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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

Part-Time Employee * Contribution Per Pay Period

Employee Only $189.43
Employee & Spouse/Registered Domestic Partner $458.96
Employee & Child(ren) $393.52
Employee & Family $633.29

Lifetime maximum

No maximum

Plan Year

2023

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.

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.

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

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

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.

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

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

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.

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: 60% 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). IVF 3 Cycles Egg freezing, Sperm Freezing, Embryo Freezing up to 3 YEAR LIMIT.

Non-Network: Not covered

GIFT and ZIFT: Not covered

Fertility drugs: Covered under Medical Lifetime Maximum on Drugs $10,000

*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-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

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 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.

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 $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)

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

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

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

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