Zip Code | 79936 |
Applicant | 1/26/1986 Male |
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 |
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 |
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 Benefytt Technologies, Inc. family of companies.
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 Benefytt Technologies, Inc. family of companies.