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Medical Plan Explained

    Medical Plan Details

    Stanford Health Care Alliance (SHCA) - Beginning Jan 1, 2021, Stanford Health Care Alliance will be the only medical plan offered to postdocs and their families.

    We remain committed to offering you the most affordable and comprehensive medical plan in 2021. Together with our Aetna and SHCA partners, we’ve created the most comprehensive SHCA network to meet your medical needs across the United States and worldwide. Checkout the directory of in-network providers available effective Jan 1, 2021.

    Your most affordable care continues to come from the SHCA network of providers. This network now supports expanded coverage beyond the core SHCA counties - the core SHCA Service Area². Beginning January 1, 2021, you can access care outside of the core SHCA service area with the same savings when you use the Aetna Choice POS II network. If you wish to receive care from a non-participating SHCA provider within the SHCA service area, you are free to do so, but keep in mind that your costs will be much higher.

    GREATEST SAVINGS

    When you receive care from a participating SHCA provider within the SHCA core service area¹ your benefits include:

    • No deductible
    • Covered services paid at 100% minus copays
      • $  5 Primary Care Physician (PCP) copay
      • $35 Specialist copay
      • $50 Urgent care facility copay
      • $300 Emergency Room (ER) admittance copay (ER copay waived if admitted to the hospital)
      • $250 copay per hospital stay
      • $250 copay for outpatient surgery when in hospital setting, no copay for free standing facility
      • $100 copay for advanced imaging service within a hospital setting, no copay for free standing facility ($100 copay does not apply when you are hospitalized and advanced imaging is required)

    If you receive care within the United States, but OUTSIDE the five core SHCA counties¹, and your care is provided by an Aetna POS II provider, services are covered as if in the SHCA service area. PLEASE NOTE: This broader Aetna network EXCLUDES Sutter Health providers, e.g. the Palo Alto Medical Foundation, with the exception of three Sutter Health facilities, Alta Bates, Mills-Peninsula and California Pacific Medical Center². Your benefits include:

    • No deductible
    • Covered services paid at 100% minus copays
      • $  5 Primary Care Physician (PCP) copay
      • $35 Specialist copay
      • $50 Urgent care facility copay
      • $300 Emergency Room (ER) admittance copay (ER copay waived if admitted to the hospital)
      • $250 copay per hospital stay
      • $250 copay for outpatient surgery when in hospital, no pay for free standing facility
      • $100 copay for advanced imaging service within a hospital setting, no copay for free standing facility ($100 copay does not apply when you are hospitalized and advanced imaging is required)

    Greatest Cost

    You may seek services from a non-participating SHCA provider within SHCA’s core service area. These services will be covered at the out-of-network rate:

    • Individual Deductible: $1,500
    • Family Deductible: $4,500
    • Individual Out-of-Pocket Max: $15,000
    • Family Out-of-Pocket Max: $45,000
    • Office Visits and Urgent Care - Includes PCP/Specialist provider visits and mental health provider visits: Aetna pays 80% of allowed amounts for service provided. Member pays 20% and any balance billing*. You do not need to meet your deductible before Aetna pays 80% of covered service.
    • Inpatient: Aetna pays 60% of allowable charge for service provided. Member pays 40% (applies towards deductible) and any balance billing*

    *Balance billing is what's left over after co-insurance is applied to the allowed amount. Balance billing does not apply to your deductible. Here is an example of how an out-of-network experience could affect billing of services:

    Let's say you went to an out-of-network facility for hospital services and they charged $10,000 for your stay, but the allowed amount is $7,000, (the allowed amount is what's considered as the reasonable and customary charge for the same service within the geographical area where you received care). The plan pays 60% of $7,000. You pay 40% plus any remaining balance, the balanced billing. Example:

    $10,000 = billed charges
    $  7,000  = Allowed amount
    ($ 4,200) = Plan pays 60% of allowed amount
    $  2,800  = Your 40% (applies towards deductible and out-of-pocket maximum)
    $  3,000 = what's left over after you and Aetna pay your percentages of allowed amounts. This is what can be balance billed to you.
    $  5,800  = your estimated financial responsibility for out-of-network care which could include balance billing. Remember, any balanced billing does not apply to your deductible or out-of-pocket maximums.

    If you went to an in-network provider for your hospital stay, your cost would be a flat fee of $250.

    This is just an example of how the SHCA medical plan might cover out-of-network medical care. Your actual costs may be different depending on the care you receive, your providers’ charges and many other factors.

    How to Know Which Providers Are In-Network Based on Location

    Location In-Network Out-of-Network

    Within the five core San Francisco Bay Area Counties

    • SHCA Providers
    • Three Sutter Health facilities - Alta Bates, Mills-Peninsula, and California Pacific Medical Center³
    • Providers not contracted with SHCA, e.g. UCSF providers, John Muir Medical Group
    • Sutter Health providers, including the Palo Alto Medical Foundation

    Outside the five core SHCA counties but within the United States

    • Aetna POS II Providers
    • Providers not contracted with Aetna POS II
    • Sutter Health providers
    International locations
    • No providers available
    • Providers not contracted with Aetna POS II


    ¹SHCA core service area consists of 5 counties: Alameda | Contra Costa | San Francisco | San Mateo | Santa Clara

    ²Three Sutter Health facilities are in-network - Alta Bates and Mills-Peninsula, however, not all physicians and providers at these facilities are in the SHCA network. Confirm your provider is in the SHCA provider directory before receiving care. California Pacific Medical Center is a full service hospital and is considered in-network. All other Sutter Health providers and facilities, including the Palo Alto Medical Foundation are out-of-network.

    Teladoc and Teladoc for Behavioral Health - Phone and Online Video Consultation will continue for 2021

    Televideo Counseling Services provided by MDLive and Inpathy will continue for 2021

    Formulary Change

    It is always a good idea to periodically review your current prescriptions with the formulary and see if there have been any changes. If you want to research the formulary, please use this link.

    Aetna Choice POS - Plan is being discontinued effective January 1, 2021

    Additional Resources