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ACA 10 Essential Benefits

The Patient Protection and Affordable Care Act (PPACA), which became effective January 1, 2014, requires that medical plans offer services from 10 categories of essential benefits and include other Affordable Care Act (ACA) requirements. All medical insurance plans offered by the Postdoctoral Scholar Benefits program have the 10 essential benefits.

All postdocs regardless of visa status must be insured by a medical plan that meets ACA standards as well as other Stanford defined coverages as noted below:

The Affordable Care Acts 10 Essential Health Benefits

  1. Ambulatory patient services (outpatient care)
    Care you receive without being admitted to a hospital, such as a doctor's office, clinic or same-day (outpatient) surgery center. Services also include home health services and hospice care
  2. Emergency services (trips to the emergency room)
    Care you receive for conditions that could lead to serious disability or death if not immediately treated, such as accidents or sudden illness. This includes transport by ambulance to the emergency room.
  3. Hospitalization (treatment in a hospital for inpatient care) Care you receive as a hospital patient, including care from doctors, nurses and other hospital staff, laboratory and other tests, medications you receive during your hospital stay, and room and board. Hospitalization coverage also includes surgeries, transplants and care received in a skilled nursing facility, such as a nursing home that specializes in the care of the elderly.
  4. Maternity and newborn care
    Care that a woman receives during pregnancy (prenatal care), including labor, delivery and post-delivery. Care for the newborn baby.
  5. Mental health services and substance/addiction treatment
    Inpatient and outpatient care provided to evaluate, diagnose, and treat a mental health condition or substance abuse disorder. Includes behavioral health treatment, counseling, and psychotherapy. Limits of plans must at parity with other medical and surgical services.
  6. Prescription drugs
    Medications that are prescribed by a doctor to treat an illness or condition.
  7. Rehabilitative services and devices  Help recovering skills, such as speech therapy after a stroke, and help developing skills, such as speech therapy for children, and devices to help gain or recover mental and physical skills lost to injury, disability or a chronic condition.
  8. Laboratory services - Testing that helps a doctor diagnose an injury, illness or condition, or to monitor the effectiveness of a particular treatment.
  9. Preventative services, wellness services, and chronic disease management
    Includes counseling, preventive care, such as physicals, immunizations and screenings designed to prevent or detect certain medical conditions. Care for chronic conditions like asthma and diabetes.
  10. Pediatric services - Care provided to infants and children, including well-baby/child visits and recommended vaccines and immunizations. Dental and vision care must be offered to children younger than 19.

Other provisions of ACA mandate the following:

  • 2018 Out-of-pocket maximums shall not exceed $7,350/individual and $14,700/family
  • Deductibles will vary, but cannot exceed the out-of-pocket maximum - J1 visa holder'ss deductible cannot exceed $500
  • A medical plan must cover at least 60% of medical expenses once a deductible is met
  • No maximum dollar limit on Essential Benefits or total medical expenses for a single incident
  • No pre-existing clauses or waiting periods

Stanford requires your policy to cover any medically necessary services, regardless of how incurred. Your policy cannot exclude services for injuries or sickness caused by:

  • participation in a riot or civil disorder
  • war or any act of war, declared or undeclared
  • extreme sports such as  skydiving, parachuting, hang glicing, glider flying, prasailing, sail planaiing, unjee jumping, rock climbing, or any other extreme sport that could cause bodily harm not mentioned here
  • self-inflicted wounds

Please email Postdoc Benefits at postdocbenefits@stanford.edu if you have any questions or need your medical policy reviewed.

Department of State (DOS) requires J visa scholars to have these additional coverages:

  • Repatriation off remains in the amount of $25,000
  • Emergency medical evacuation to home country in the amount of $50,000

Repatriation of remains and medical evacuation coverage is available for an additional monthly charge of $1.25 through the Postdoctoral Scholar Benefits program by electing the Extended Travel Assistance Program through UnitedHealthcare Global. You may elect this plan through Benelogic within 31 days of your postdoc appointment start date or during Open Enrollment. Open Enrollment is usually in late October early November with all elections becoming effective January 1 of the following year.

 

Updated 11/27/2018