Market HMO 5250 HSA - Mercy Plan Details for 2020- HealthPocket

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Zip Code43228
Applicant12/5/1984 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameMarket HMO 5250 HSA - Mercy
Plan IDqhp-99969OH0080044
Plan Year2020
Insurance ProviderMedical Mutual
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$5,250
Out-of-Pocket Maximum$6,900
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or IllnessNo Charge after Deductible
Specialist VisitNo Charge after Deductible
Laboratory Outpatient and Professional Services0.00% Coinsurance after deductible
X-rays and Diagnostic Imaging0.00% Coinsurance after deductible
Deductible - Family$10500
Out-of-Pocket Maximum - Family$13800

Prescription drug coverage

Generic Drugs$40 Copay
Preferred Brand Drugs$80 Copay
Non-Preferred Brand Drugs50% Coinsurance after deductible
Specialty Drugs50% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttps://providersearch.medmutual.com/default.aspx?product=SM%2b

Hospital services

Emergency Room ServicesNo Charge after Deductible
Inpatient Hospital Services (e.g., Hospital Stay)No Charge after Deductible
Inpatient Physician and Surgical ServicesNo Charge after Deductible

Maternity

Prenatal and Postnatal Care0.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services0.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services0.00% Coinsurance after deductible

Vision Coverage

Routine Eye Exam for ChildrenNo Charge
Eye Glasses for Children0.00% Coinsurance after deductible

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Hospice Services
Infertility Treatment
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
Imaging (CT/PET Scans, MRIs)
Preventive Care/Screening/Immunization
Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Well Baby Visits and Care
Transplant
Accidental Dental
Dialysis
Allergy Testing
Chemotherapy
Radiation
Diabetes Education
Prosthetic Devices
Infusion Therapy
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Reconstructive Surgery
More Excluded BenefitsLong-Term/Custodial Nursing Home Care
Bariatric Surgery
Cosmetic Surgery
Hearing Aids
Routine Foot Care
Acupuncture
Weight Loss Programs
Dental Check-Up for Children
Abortion for Which Public Funding is Prohibited
PremiumPlan NameDeductible
from $270
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Ambetter Essential Care 4 HSA (2020)
$5,400.00Select
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Market HMO 5250 HSA - NE Ohio
$5,250.00Select
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Market HMO 5250 HSA - OhioHealth
$5,250.00Select
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  • Phone Number
    (614) 486-2000
  • Office Locations
    5131 Beacon Hill Rd
    Columbus, OH 43228
5131 Beacon Hill Rd Columbus OH, 43228

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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).