Zip Code | 11226 |
Applicant | 1/22/1986 Male |
Insurance Type | ACA (Obamacare) |
Plan Name | Fidelis Care Gold ST INN Pediatric Dental Dep25 Free Telemedici |
Plan ID | hhs-25303NY0030001 |
Plan Year | 2020 |
Insurance Provider | Fidelis Care |
Metal Level | Gold |
Plan Type | HMO |
Deductible | $600 |
Out-of-Pocket Maximum | $4,000 |
Plan Highlights |
Costs for Medical Care | |
---|---|
Primary Care Visit to Treat an Injury or Illness | $25 Copay after deductible |
Specialist Visit | $40 Copay after deductible |
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 | $40 Copay after deductible |
Deductible - Family | $1200 per group |
Out-of-Pocket Maximum - Family | $8000 per group |
Prescription drug coverage | |
---|---|
Generic Drugs | $10 Copay |
Preferred Brand Drugs | $35 Copay |
Non-Preferred Brand Drugs | $70 Copay |
Specialty Drugs | Not Applicable |
Access to doctors and hospitals | |
---|---|
Provider directory URL | http://www.fideliscare.org/apps/providersearch/ |
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 Services | $150 Copay after deductible |
Inpatient Hospital Services (e.g., Hospital Stay) | $1000 Copay per Stay after deductible |
Inpatient Physician and Surgical Services | $100 Copay after deductible |
Emergency Transportation or Ambulance Service | $150 Copay after deductible |
Maternity | |
---|---|
Prenatal and Postnatal Care | Not Applicable |
Delivery and all inpatient services for maternity care | $1100 Copay after deductible |
Mental Health | |
---|---|
Mental/Behavioral Health Outpatient Services | $25 Copay after deductible |
Mental/Behavioral Health Inpatient Services | $1000 Copay per Stay after deductible |
Substance use disorder outpatient services | $25 Copay after deductible |
Substance use disorder inpatient services | $1000 Copay per Stay after deductible |
Medical Management Programs | |
---|---|
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 | 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 Bariatric Surgery 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 Chiropractic Care Applied Behavior Analysis Based Therapies Cochlear Implants Second Opinion Accidental Dental Allergy Testing Chemotherapy Diabetes Education Dialysis Infusion Therapy Laboratory Outpatient and Professional Services Prosthetic Devices Radiation Reconstructive Surgery Transplant Treatment for Temporomandibular Joint Disorders Well Baby Visits and Care Breast Reconstructive Surgery Cardiac Rehabilitation Prostate Cancer Screening Assistive Communication Devices Autologous Blood Banking Gym Membership Reimbursement Medical Supplies Preadmission Testing Design Diabetic Equipment and Supplies Family Planning Services Sterilization Procedures for Men Telemedicine Outpatient Facility Fee (e.g., Ambulatory Surgery Center) |
More Limited Benefits | Skilled Nursing Facility Hearing Aids Home Health Care Services Outpatient Rehabilitation Services Habilitation Services Hospice Services Dental Check-Up for Children Inpatient Rehabilitation Services Abortion for Which Public Funding is Prohibited Rehabilitative Occupational and Rehabilitative Physical Therapy Rehabilitative Speech Therapy Contact Lenses for Children |
More Excluded Benefits | Acupuncture Cosmetic Surgery Long-Term/Custodial Nursing Home Care Private-Duty Nursing Weight Loss Programs Routine Foot Care Nutritional Counseling |
Premium | Plan Name | Deductible | |
---|---|---|---|
from $234 | Fidelis Care Gold for Children, Child Only, ST, INN, Fidelis Ca | $600.00 | Select |
from $268 | Standard Gold Child Only ST OON IHC Network | $600.00 | Select |
from $304 | Healthfirst Gold Leaf, Child-Only, ST, INN, Pediatric Dental, F | $600.00 | Select |
from $348 | HMO Copayment 20, Gold Child Only, ST, INN | $600.00 | Select |
from $355 | Gold Standard Child Only ST INN | $600.00 | Select |
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.
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.
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.
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.
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.