2019 Avera 5500 Plan Details - HealthPocket

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Zip Code57106
Applicant10/15/1984 Male
Coverage Start10/16/2019
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameAvera 5500
Plan IDhhs-60536SD0020023
Plan Year2019
Insurance ProviderAvera Health Plans
Metal LevelBronze
Plan TypePPO
Deductible$5,500
Out-of-Pocket Maximum$7,900
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$40 Copay with deductible, 40.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Specialist Visit40.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services40.00% Coinsurance after deductible
X-rays and Diagnostic Imaging40.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans40.00% Coinsurance after deductible
Deductible - Family$11000 per group
Out-of-Pocket Maximum - Family$15800 per group

Prescription drug coverage

Generic Drugs$20 Copay with deductible
Preferred Brand Drugs$75 Copay with deductible
Non-Preferred Brand Drugs$150 Copay with deductible
Specialty Drugs40.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttps://www.averahealthplans.com/insurance/find-a-provider/
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?Yes - Emergency or urgent care services are covered if traveling outside of our service area. No coverage for health services if you travel outside our service area for the purpose of seeking medical treatment.
Does this plan cover services outside the country?Not Covered

Hospital services

Emergency Room Services40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)40.00% Coinsurance after deductible
Inpatient Physician and Surgical Services40.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service40.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care40.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care40.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$40 Copay with deductible, 40.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Mental/Behavioral Health Inpatient Services40.00% Coinsurance after deductible
Substance use disorder outpatient services$40 Copay with deductible, 40.00% Coinsurance after deductible. See plan brochure for when Copay is applicable.
Substance use disorder inpatient services40.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy
Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareIncluded
Child Dental Coverage - Basic Dental CareIncluded
Child Dental Coverage - OrthodontiaIncluded
Child Dental Coverage - Major Dental CareIncluded

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Infertility Treatment
Private-Duty Nursing
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Chiropractic Care
Accidental Dental
Allergy Testing
Chemotherapy
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Prosthetic Devices
Radiation
Reconstructive Surgery
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
More Limited BenefitsSkilled Nursing Facility
Bariatric Surgery
Hospice Services
Dental Check-Up for Children
Diabetes Education
More Excluded BenefitsAcupuncture
Cosmetic Surgery
Hearing Aids
Long-Term/Custodial Nursing Home Care
Weight Loss Programs
Routine Foot Care
Abortion for Which Public Funding is Prohibited
Nutritional Counseling
PremiumPlan NameDeductible
from $258
Avera Preferred 5500
$5,500.00Select
from $315
Avera Preferred 5500
$5,500.00Select
from $392
Avera 5500
$5,500.00Select
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  • Phone Number
    (605) 322-5180
  • Office Locations
    2100 S Marion Rd
    Sioux Falls, SD 57106
2100 S Marion Rd Sioux Falls SD, 57106
  • What is a bronze plan?

    Bronze Plan is a type of Metal Plan on the Health Insurance Marketplace. Bronze Plans qualify for Tax Credits and have low premiums. Generally speaking, a Bronze Plan is intended to have the lowest premium of the 4 new categories of health plans under the Affordable Care Act but charge the highest out-of-pocket costs for healthcare services.

  • How are Bronze Plans different than other Obamacare health plans?

    The fundamental difference among the new Obamacare health plans is the percentage of covered medical costs paid by the health plan. The Bronze Plan pays 60% of the covered medical costs among its enrollees while the other Obamacare health plans pay a higher percentage of these costs.

  • How much does a Bronze Plan cost?

    The monthly premium for a Bronze Plan depends on the insurer from whom you purchase the plan, the number of people to be insured by the plan, your age, whether you smoke, and the region in which you live. You can use HealthPocket’s comparison tool to compare Bronze Plan premiums in your area. Another important factor to remember is Advanced Premium Tax Credits which can subsidize bronze plan premiums if an individual meets eligibility criteria.

  • When Can I Enroll in a Bronze Plan?

    The annual enrollment period for the 2018 plan year will begin on November 1, 2017 and continue through December 15, 2017.

    In 2015 there had been a Special Enrollment Period for many facing the uninsured penalty on their 2014 tax return. There is no guarantee that a similar Special Enrollment Period will be granted in 2017. See our Open Enrollment article for more information.

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).