2019 HealthyBlueHMO Gold $1,750 Plan Details

Insurance Type	ACA (Obamacare)
Plan Name	HealthyBlueHMO Gold $1,750
Plan ID	hhs-28137MD0370003
Plan Year	2019
Insurance Provider	CareFirst BlueCross BlueShield
Metal Level	Gold
Plan Type	HMO
Deductible	$1,750
Out-of-Pocket Maximum	$6,650
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	No Charge
Specialist Visit	$30 Copay
Laboratory Outpatient and Professional Services	$15 Copay
X-rays and Diagnostic Imaging	$65 Copay
Diagnostic Imaging such as MRIs, CT, and PET scans	$250 Copay
Deductible - Family	$3500 per group
Out-of-Pocket Maximum - Family	$13300 per group

Prescription drug coverage
Generic Drugs	Not Applicable
Preferred Brand Drugs	$50 Copay after deductible
Non-Preferred Brand Drugs	$70 Copay after deductible
Specialty Drugs	$100 Copay after deductible

Access to doctors and hospitals
Provider directory URL	https://member.carefirst.com/mos/#/fappublic/search/standard?sType=M&planName=BlueChoice%20HMO
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 Services Only
Does this plan cover services outside the country?	Yes - Emergency Services Only

Hospital services
Emergency Room Services	$300 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	$450 Copay per Day after deductible
Inpatient Physician and Surgical Services	$30 Copay after deductible
Emergency Transportation or Ambulance Service	$30 Copay after deductible

Maternity
Prenatal and Postnatal Care	Not Applicable
Delivery and all inpatient services for maternity care	$450 Copay after deductible

Mental Health
Mental/Behavioral Health Outpatient Services	Not Applicable
Mental/Behavioral Health Inpatient Services	$450 Copay per Day after deductible
Substance use disorder outpatient services	Not Applicable
Substance use disorder inpatient services	$450 Copay per Day after deductible

Medical Management Programs
Does this plan offer disease managment programs?	Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does this plan offer a wellness program?	Included

Vision Coverage
Routine Eye Exam for Children	Included
Eye Glasses for Children	Included
Routine Eye Exam for Adults	Included

Child Dental Coverage
Child Dental Coverage - Routine Dental Care	Included
Child Dental Coverage - Basic Dental Care	Included
Child Dental Coverage - Orthodontia	Included
Child Dental Coverage - Major Dental Care	Included

Adult Dental Coverage
Adult Dental Coverage - Routine Dental Care	Not Covered
Adult Dental Coverage - Basic Dental Care	Not Covered
Adult Dental Coverage - Orthodontia	Not Covered
Adult Dental Coverage - Major Dental Care	Not Covered

Exclusions and Limitations
More Included Benefits	Other Practitioner Office Visit (Nurse, Physician Assistant) Preventive Care/Screening/Immunization Acupuncture Bariatric Surgery Infertility Treatment Weight Loss Programs 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 Durable Medical Equipment Hospice Services Abortion for Which Public Funding is Prohibited Accidental Dental Allergy Testing Chemotherapy Diabetes Education Dialysis Infusion Therapy Laboratory Outpatient and Professional Services Nutritional Counseling Prosthetic Devices Radiation Reconstructive Surgery Transplant Treatment for Temporomandibular Joint Disorders Well Baby Visits and Care
More Limited Benefits	Skilled Nursing Facility Hearing Aids Outpatient Rehabilitation Services Habilitation Services Dental Check-Up for Children Chiropractic Care Rehabilitative Occupational and Rehabilitative Physical Therapy Rehabilitative Speech Therapy
More Excluded Benefits	Cosmetic Surgery Long-Term/Custodial Nursing Home Care Private-Duty Nursing Routine Foot Care

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Premium

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HealthyBluePPO Gold $1,750

$1,750.00

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from $634

HealthyBluePPO Gold $1,750

$1,750.00

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Phone Number
(410) 601-5209
Office Locations
2401 W Belvedere Ave
Baltimore, MD 21215

2401 W Belvedere Ave Baltimore MD, 21215

What is the Gold Plan?
ObamaCare’s Gold Plan is a type of Metal Plan on the Health Insurance Marketplace. Gold Plans qualify for Tax Credits, have high premiums, and good cost sharing. Gold plans mean higher premiums, less Tax Credits, but much better cost sharing on average than Silver or Bronze.
How are Gold 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 Gold Plan typically pays 80% of covered medical costs.
How much does a Gold Plan cost?
The monthly premium for a Gold 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 your geographic region. You can use HealthPocket’s comparison tool to compare Gold Plan premiums in your area.
When Can I Enroll in a Gold Plan?
The Open Enrollment period for the 2018 Affordable Care Act health plans begins November 1, 2017 and ends December 15, 2017. See our Open Enrollment article for more information.

Zip Code	21215 (edit)
Applicant	12/17/1983 Male (edit)
Coverage Start	12/18/2018 (edit)

Zip Code	21215 (edit)
Applicant	12/17/1983 Male (edit)
Coverage Start	12/18/2018 (edit)

HealthyBlueHMO Gold $1,750

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Benefits & Coverage

Costs for Medical Care

Prescription drug coverage

Access to doctors and hospitals

Hospital services

Maternity

Mental Health

Medical Management Programs

Vision Coverage

Child Dental Coverage

Adult Dental Coverage

Exclusions and Limitations

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