Preferred Provider Organization
High-Deductible Health Plan FAQs
These questions and answers summarize some of the plan’s highlights. For a complete description of your benefits, please refer to the appropriate Plan Summary document in the Resource Library section of the Benefits Web site. If there are any differences between this information and the plan documents, the plan documents will govern.
What is the Blue Shield High-Deductible Health Plan?
Blue Shield’s High Deductible Health Plan (HDHP) is a Preferred Provider Organization (PPO) with a high deductible. You can obtain preventive care at no charge if you see a Blue Shield provider. All other medical services, including prescription drugs, require you to meet your deductible before Blue Shield pays any benefits.
A PPO contracts with health care providers (doctors, hospitals, and medical groups) to deliver medical services at discounted prices. The plan is designed to lower your out-of-pocket costs when you see a network provider for your care. You can see other doctors who are not contracted with Blue Shield, but your out-of-pocket costs will be higher.
The Blue Shield HDHP lets you see any licensed provider for your care, and you have coverage worldwide for both routine care and emergencies.
The high deductible of this plan allows you to establish an individual Health Savings Account (HSA). For more information on what an HSA is and how it works, go to the Medical & Life section of the Stanford Benefits Web site and read the FAQ on Health Savings Accounts. Also see the recorded workshop called “Blue Shield High Deductible PPO and Your Health Savings Account (HSA): Making Them Work Together.”
Do I have to file a claim each time I see the doctor?
No, you don’t have to file claims if you see Blue Shield contracted providers. If you choose to go to an out-of-network provider, you may need to file a claim.
Are there any pre-existing conditions exclusions?
No, there are no pre-existing condition exclusions in any of Stanford University’s health plans.
Is there a lifetime benefit maximum on this plan?
No. Effective January 1, 2011, the overall lifetime benefit maximum has been removed.
How do I find out if the provider I’m seeing is in the Blue Shield network?
The easiest way to find out if your provider is contracted with Blue Shield is to ask. You can also contact Blue Shield Member Services at the number on your Blue Shield ID card, call (800) 873-3605, or view the Blue Shield provider directory at their Web site at http://www.blueshieldca.com.
Can I change to another health plan if my doctor leaves Blue Shield’s network in the middle of the year?
Because the Blue Shield network provides access to any licensed provider – in or out of the Blue Shield network – you may not change to another health plan mid-year if your doctor leaves the Blue Shield network.
Stanford cannot guarantee that any doctor, medical group or hospital will continue to participate in any health plan’s network.
Do I need to choose a Primary Care Physician?
No, in a PPO you do not need to choose a primary care physician. You can self-refer to any licensed provider including a specialist although your costs will be lower if you choose a contracted provider.
How does the Blue Shield HDHP plan work?
When you get care from a Blue Shield provider, have the provider file a claim with Blue Shield for you. Blue Shield will send you a statement called an Explanation of Benefits that will show what your out-of-pocket costs will be.
Filing a claim first before paying your provider ensures that you get the Blue Shield network negotiated discounts. You should follow this process even if still paying toward your deductible.
When seeing a provider who is not in the Blue Shield network you may need to file the claim with Blue Shield. We suggest you file your claim before paying the provider so Blue Shield can inform you what your actual out-of-pocket costs will be.
When picking up a prescription at a Blue Shield network pharmacy, they will file the claim for you. Use your Blue Shield Explanation of Benefits (EOB) to reimburse yourself from your HSA. If you pick up a prescription at a non-network pharmacy, you will need to pay for the prescription and then file a claim with Blue Shield. You can find Blue Shield prescription drug claim forms in the Resource Library.
How does my Health Savings Account work with the Blue Shield HDHP plan?
We have a recorded workshop on this topic. Look in the Medical & Life section of the Stanford Benefits Web site for the workshop called “Blue Shield High Deductible PPO and Your Health Savings Account (HSA): Making Them Work Together.”
What is a deductible?
The deductible is the amount you must pay out-of-pocket before Blue Shield starts paying any benefits.
After you have paid your deductible you will share the cost of your medical expenses with Blue Shield. This is called co-insurance. For example, after you meet the deductible, Blue Shield will pay 80% of your expenses and your co-insurance will be 20% of your expenses.
If you see providers who are not part of the Blue Shield network, your co-insurance is higher. Co-insurance is based on Blue Shield’s allowable amount (see next question for “allowable amount”).
Look in the Medical & Life section of the Stanford Benefits Web site, http://benefits.stanford.edu, and click on the link to compare medical plans for more information on your out-of-pocket costs.
What is the Blue Shield Allowable Amount?
The allowable amount is what Blue Shield uses to determine how much to pay when you see a provider outside the Blue Shield network. The allowable amount is based on a variety of factors and generally reduces the amount paid by Blue Shield (which, in turn, increases what you have to pay out of your pocket).
Why are my bills so much higher when I see a non-network provider?
Since the provider is not contracted with Blue Shield you will have to pay for any expenses Blue Shield does not cover. Even after you have paid your 40% out-of-network co-insurance, you will need to pay any remaining part of the provider’s bill.
Before you pay the bill, we recommend you wait until you receive Blue Shield’s Explanation of Benefits (EOB) showing your share of the cost.
When you see a Blue Shield provider, your out-of-pocket costs are lower and more predictable.
Are there any benefits that don’t require a deductible or co-insurance?
Yes. Stanford’s Blue Shield HDHP plan covers certain preventive care at no charge. Look in the Medical & Life section of the Stanford Benefits Web site and click on the link to compare medical plans for more information on your out-of-pocket costs. You can also review the Blue Shield High Deductible PPO Plan Summary located in the Resource Library of the Benefits Web site, http://benefits.stanford.edu
How can I find out in advance if my medical services will be covered?
Look in the Medical & Life section of the Stanford Benefits Web site and click on the link to compare medical plans for more information on what the HDHP plan covers. You may also look
at the Blue Shield High Deductible PPO Plan Summary located in the Resource Library of the Benefits Web site, http://benefits.stanford.edu. Your doctor can also contact Blue Shield whenever there is a question about the treatment they want to provide and whether or not Blue Shield will cover it. Blue Shield’s actual coverage is generally determined when your doctor submits the claim for your services.
What is Coordination of Benefits?
Coordination of Benefits helps to prevent duplication of payments for the same services if you or your dependents are covered under more than one health plan. For additional information please see your PPO plan’s Plan Summary, located in the Resource Library, or call the plan’s Customer Service number on your medical ID card.
What if I need medical care outside of California or of the U.S.?
Benefits will be provided for covered services you receive anywhere in the world. Blue Shield has network providers outside of the United States. You are encouraged to see Blue Shield providers to help reduce your costs, but you may still see any provider to get needed care.
You can access services received outside of the United States through the BlueCard Worldwide® Network. If you need care while out of the country, call the toll-free BlueCard Program Access number at (800) 810-2583, or call collect at (804) 673-1177, 24 hours a day, seven days a week.
Before traveling abroad, call Blue Shield Customer Service at (800) 873-3605 to find out what you need to make your plan work for you when you travel. You can also visit Blue Shield’s Web site at http://www.blueshieldca.com.
In an emergency, go directly to the nearest hospital. As soon as possible you should call Blue Shield at (800) 343-1691 or call collect at (804) 673-1177, 24 hours a day, seven days a week.
How are prescription drugs covered?
The cost of your medication depends on if you purchase a generic or brand drug. Your cost also depends on whether or not you purchase drugs included on Blue Shield’s formulary.
What is a formulary?
A formulary is a list of approved prescription drugs covered by Blue Shield. Blue Shield’s formulary has three tiers: generic, brand and non-formulary. These three tiers provide access to as many drugs as possible, but brand and non-formulary tiers are more expensive, so they increase your out-of-pocket costs.
You can find the formulary on Blue Shield’s Web site at http://www.blueshieldca.com or you can call Blue Shield Member Services at (800) 873-3605.
Are infertility drugs covered?
In most cases, infertility drugs are covered but the cost is limited. For more information, look in the Medical & Life section of the Stanford Benefits Web site and click on the link to compare medical plans for more information on your out-of-pocket costs and what’s covered. You may also review the Blue Shield High Deductible PPO Plan Summary located in the Resource Library of the Benefits Web site, http://benefits.stanford.edu. You can also contact Blue Shield Member Services at (800) 873-3605.
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