Stanford Health Care Alliance

Find plan documentation and resources for Stanford Health Care Alliance (SHCA)

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. Check out the directory of in-network providers.

Your most affordable care continues to come from the SHCA network of providers. This network supports expanded coverage beyond the core SHCA counties - the core SHCA Service Area¹. 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 are paid at 100% after applicable co-pays
  • $5 Primary Care Physician (PCP) co-pay
  • $40 Specialist co-pay - the Plan does not require a referral from a PCP
  • $40 Urgent care facility co-pay
  • $250 Emergency Room (ER) admittance co-pay (ER co-pay waived if admitted to the hospital)
  • $250 co-pay per hospital stay
  • $250 co-pay for outpatient surgery when in a hospital setting, no co-pay for freestanding facility
  • $100 co-pay for advanced imaging service within a hospital setting, no co-pay for the freestanding facility ($100 co-pay 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, except three Sutter Health facilities, Alta Bates, Mills-Peninsula, and California Pacific Medical Center². Your benefits include:

• No deductible
• Covered services are paid at 100% minus co-pays
  • $5 Primary Care Physician (PCP) co-pay
  • $40 Specialist co-pay - the Plan does not require a referral from a PCP
  • $40 Urgent care facility co-pay
  • $250 Emergency Room (ER) admittance co-pay (ER co-pay waived if admitted to the hospital)
  • $250 co-pay per hospital stay
  • $250 co-pay for outpatient surgery when in hospital, no pay for freestanding facility
  • $100 co-pay for advanced imaging service within a hospital setting, no co-pay for the freestanding facility ($100 co-pay 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 the 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 the covered service.
• Inpatient: Aetna pays 60% of the allowable charge for the 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 the 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 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 balance billing. Example:

$10,000 = billed charges
$  7,000  = Allowed amount
($ 4,200) = Plan pays 60% of the allowed amount
$  2,800  = Your 40% (applies towards the 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 balanced billed to you.
$  5,800  = your estimated financial responsibility for out-of-network care which could include balance billing. Remember, 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 differ depending on the care you receive, your providers’ charges, and many other factors.

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

Traveling Outside the U.S.

SHCA provides “Emergency Care” coverage anywhere you may experience an emergency that is life-threatening in nature.

To learn more about SHCA Emergency Care benefits:

• Call SHCA Member Care Services at 855-345-SHCA (7422)
• If you need to file a claim for emergency care received while overseas, contact SHCA to have an international claim form sent to you

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

²_{Teladoc and Teladoc for Behavioral Health - Phone and Online Video Consultation Services are free with a mental health provider or primary care physician. Specialist visits are $20 per visit}

³Sutter Health providers are also out-of-network except for 3 facilities - Alta Bates, Mills-Peninsula, and California Medical Center. All other Sutter Health providers and facilities, including the Palo Alto Medical Foundation, are out-of-network.