Community Health Choice HMO Bronze 003 Plan Details for 2021- HealthPocket

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Applicant Info
Applicant
Date of birth
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Gender
male
female
Income
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Zip Code	79936 (edit)
Applicant	1/26/1986 Male (edit)

Insurance Type	ACA (Obamacare)
Plan Name	Community Health Choice HMO Bronze 003
Plan ID	hhs-27248TX0010003
Plan Year	2020
Insurance Provider	Community Health Choice
Metal Level	Expanded Bronze
Plan Type	HMO
Deductible	$7,150
Out-of-Pocket Maximum	$8,150
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	$40 Copay
Specialist Visit	$70 Copay
Laboratory Outpatient and Professional Services	$40 Copay after deductible
X-rays and Diagnostic Imaging	$40 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans	30.00% Coinsurance after deductible
Deductible - Family	$14300 per group
Out-of-Pocket Maximum - Family	$16300 per group

Prescription drug coverage
Generic Drugs	$15 Copay
Preferred Brand Drugs	$70 Copay after deductible
Non-Preferred Brand Drugs	$120 Copay after deductible
Specialty Drugs	45.00% Coinsurance after deductible

Access to doctors and hospitals
Provider directory URL	http://www.communityhealthchoice.org
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?	No - For emergency only.
Does this plan cover services outside the country?	Not Covered

Hospital services
Emergency Room Services	30.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	30.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	$0 Copay after deductible
Emergency Transportation or Ambulance Service	$70 Copay after deductible

Maternity
Prenatal and Postnatal Care	$70 Copay after deductible
Delivery and all inpatient services for maternity care	30.00% Coinsurance after deductible

Mental Health
Mental/Behavioral Health Outpatient Services	$40 Copay
Mental/Behavioral Health Inpatient Services	30.00% Coinsurance after deductible
Substance use disorder outpatient services	$40 Copay
Substance use disorder inpatient services	30.00% Coinsurance after deductible

Medical Management Programs
Does this plan offer disease managment programs?	Asthma, Diabetes, Heart Disease, Pregnancy
Does this plan offer a wellness program?	Not Covered

Vision Coverage
Routine Eye Exam for Children	Included
Eye Glasses for Children	Included
Routine Eye Exam for Adults	Not Covered

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

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 Private-Duty Nursing Imaging (CT/PET Scans, MRIs) Outpatient Surgery Physician/Surgical Services Urgent Care Centers or Facilities Inpatient Physician and Surgical Services Outpatient Rehabilitation Services Habilitation 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 Benefits	Skilled Nursing Facility Hearing Aids Home Health Care Services Chiropractic Care
More Excluded Benefits	Acupuncture Bariatric Surgery Cosmetic Surgery Infertility Treatment Long-Term/Custodial Nursing Home Care Weight Loss Programs Dental Check-Up for Children Abortion for Which Public Funding is Prohibited

+ See All Coverage Details

Premium	Plan Name	Deductible
from $322	Oscar Bronze Simple ($3 Prescription List + Free 24/7 Virtual V	$7,300.00	Select
from $455	Oscar Silver Classic Copay ($3 Prescription List + Free 24/7 Vi	$7,000.00	Select
from $461	Ambetter Balanced Care 5 (2021)	$7,350.00	Select
from $466	Ambetter Balanced Care 5 (2021) + Vision	$7,350.00	Select
from $483	Ambetter Balanced Care 5 (2021) + Vision + Adult Dental	$7,350.00	Select

Last Name

Location/Distance

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Marisela, Gomez

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Saranya, Gangupalli

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Jose, Ruiz

Huma Lodhi, M.D.

Phone Number
(915) 225-3807
Office Locations
11351 James Watt Dr
El Paso, TX 79936

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ZIP Code
County
Applicant Info
Applicant
Date of birth
//
Gender
male
female
Income
$

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Community Health Choice HMO Bronze 003

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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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