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
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
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.
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.
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
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
Prenatal and Postnatal Physician Office Visits:
Network: 100% no deductible
Non-Network: 50% after deductible
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.
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
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
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
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
**Pre-authorization required
Network: 60% after deductible
Non-Network: 50% after deductible
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
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
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
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
Non-Network: not covered
Hospice Care
Network: 60% after deductible
Non-Network: 50% after deductible (prior authorization required)
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
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."
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
Non-Network: 50% after deductible
Magnetic resonance imaging - MRI
**Pre-authorization required
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
Pre-authorization may apply
Non-Network: 50% after deductible
Pre-authorization may apply
Occupational Therapy
Network: 60% after deductible
Non-Network: 50% 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).
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
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
Non-Network: 50% after deductible
Surgery : Facility Charges
Network: 60% after deductible
Non-Network 50% of billed charges after deductible
Non-Network 50% of billed charges after deductible
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: 100% no 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: 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.
*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
*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
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
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.
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