Ambetter Essential Care 4 HSA (2020) Plan Details for 2020- HealthPocket

Ambetter Essential Care 4 HSA (2020)

$363.63/mo

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Zip Code79936
Applicant4/8/1985 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameAmbetter Essential Care 4 HSA (2020)
Plan IDhhs-29418TX0140047
Plan Year2020
Insurance ProviderAmbetter
Metal LevelExpanded Bronze
Plan TypeEPO
Deductible$5,400
Out-of-Pocket Maximum$6,750
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness30.00% Coinsurance after deductible
Specialist Visit30.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services30.00% Coinsurance after deductible
X-rays and Diagnostic Imaging30.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans30.00% Coinsurance after deductible
Deductible - Family$10800 per group
Out-of-Pocket Maximum - Family$13500 per group

Prescription drug coverage

Generic Drugs30.00% Coinsurance after deductible
Preferred Brand Drugs30.00% Coinsurance after deductible
Non-Preferred Brand Drugs40.00% Coinsurance after deductible
Specialty Drugs40.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttps://providersearch.ambetterhealth.com/
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?Not Covered
Does this plan cover services outside the country?Not Covered

Hospital services

Emergency Room Services30.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)30.00% Coinsurance after deductible
Inpatient Physician and Surgical Services30.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service30.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care30.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care30.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services30.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services30.00% Coinsurance after deductible
Substance use disorder outpatient services30.00% Coinsurance after deductible
Substance use disorder inpatient services30.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain
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 CareNot Covered
Child Dental Coverage - Basic Dental CareNot Covered
Child Dental Coverage - OrthodontiaNot Covered
Child Dental Coverage - Major Dental CareNot Covered

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
Imaging (CT/PET Scans, MRIs)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Durable Medical Equipment
Hospice Services
Routine Foot Care
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
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
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsSkilled Nursing Facility
Hearing Aids
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
More Excluded BenefitsAcupuncture
Bariatric Surgery
Cosmetic Surgery
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Abortion for Which Public Funding is Prohibited
PremiumPlan NameDeductible
from $236
Oscar Classic Bronze
$5,500.00Select
from $276
Ambetter Essential Care 4 HSA (2020)
$5,400.00Select
from $288
Classic Bronze (Free 24/7 Telemedicine + Free Preventive Care)
$5,500.00Select
from $350
Ambetter Essential Care 4 HSA (2020)
$5,400.00Select
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  • Phone Number
    (915) 855-7900
  • Office Locations
    1418 George Dieter Dr
    El Paso, TX 79936
1418 George Dieter Dr El Paso TX, 79936

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HealthPocket.com provides information on insurance products. If you choose to obtain a quote or apply for an insurance plan, you may be transferred to a partner website to complete your request. Always review the privacy and terms of use of the partner website.

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).