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

Ambetter Essential Care 4 HSA (2020)

$333.66/mo

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Zip Code63129
Applicant12/5/1984 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameAmbetter Essential Care 4 HSA (2020)
Plan IDqhp-99723MO0090027
Plan Year2020
Insurance ProviderCeltic Insurance Company
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% Coinsurance after deductible
Specialist Visit30% Coinsurance after deductible
Laboratory Outpatient and Professional Services30% Coinsurance after deductible
X-rays and Diagnostic Imaging30% Coinsurance after deductible
Deductible - Family$10800
Out-of-Pocket Maximum - Family$13500

Prescription drug coverage

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

Access to doctors and hospitals

Provider directory URLhttp://ambetter.homestatehealth.com/

Hospital services

Emergency Room Services30% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)30% Coinsurance after deductible
Inpatient Physician and Surgical Services30% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care30% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services30% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services30% Coinsurance after deductible

Vision Coverage

Routine Eye Exam for ChildrenNot Applicable
Eye Glasses for ChildrenNot Applicable

Exclusions and Limitations

More Included BenefitsAccidental Dental
Dialysis
Allergy Testing
Chemotherapy
Radiation
Diabetes Education
Prosthetic Devices
Infusion Therapy
Other Practitioner Office Visit (Nurse, Physician Assistant)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Hospice Services
Private-Duty Nursing
Urgent Care Centers or Facilities
Home Health Care Services
Inpatient Physician and Surgical Services
Skilled Nursing Facility
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Durable Medical Equipment
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Preventive Care/Screening/Immunization
Routine Foot Care
Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Well Baby Visits and Care
Transplant
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Reconstructive Surgery
More Excluded BenefitsInfertility Treatment
Long-Term/Custodial Nursing Home Care
Bariatric Surgery
Cosmetic Surgery
Acupuncture
Weight Loss Programs
Dental Check-Up for Children
Abortion for Which Public Funding is Prohibited
PremiumPlan NameDeductible
from $327
Ambetter Essential Care 4 HSA (2020)
$5,400.00Select
from $352
Cigna Connect 5500
$5,500.00Select
from $413
Anthem Bronze Pathway X 5450
$5,450.00Select
from $432
Anthem Bronze Pathway X 20 for HSA
$5,250.00Select
from $466
Cigna Connect 5500
$5,500.00Select
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  • Phone Number
    (314) 487-8724
  • Office Locations
    4530 Lemay Ferry Rd
    Saint Louis, MO 63129
4530 Lemay Ferry Rd Saint Louis MO, 63129

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).