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Applicant Info
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Date of birth
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Gender
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Zip Code	43228 (edit)
Applicant	12/5/1984 Male (edit)

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Insurance Type	ACA (Obamacare)
Plan Name	Confident Care Gold 1 +Vision
Plan ID	qhp-64353OH0040001
Plan Year	2020
Insurance Provider	Molina Healthcare
Metal Level	Gold
Plan Type	HMO
Deductible	$2,925
Out-of-Pocket Maximum	$6,000
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	$10 Copay
Specialist Visit	$50 Copay
Laboratory Outpatient and Professional Services	Not Applicable
X-rays and Diagnostic Imaging	20.00% Coinsurance after deductible
Deductible - Family	$5850
Out-of-Pocket Maximum - Family	$12000

Prescription drug coverage
Generic Drugs	$10 Copay
Preferred Brand Drugs	$50 Copay
Non-Preferred Brand Drugs	30% Coinsurance after deductible
Specialty Drugs	30% Coinsurance after deductible

Access to doctors and hospitals
Provider directory URL	https://providersearch.molinahealthcare.com/Provider/ProviderSearch?RedirectFrom=MolinaStaticWeb&memstate=oh&State=oh&Coverage=NA

Hospital services
Emergency Room Services	20% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	20% Coinsurance after deductible
Inpatient Physician and Surgical Services	20% Coinsurance after deductible

Maternity
Prenatal and Postnatal Care	Not Applicable

Mental Health
Mental/Behavioral Health Outpatient Services	Not Applicable
Mental/Behavioral Health Inpatient Services	20.00% Coinsurance after deductible

Vision Coverage
Routine Eye Exam for Children	Not Applicable
Eye Glasses for Children	Not Applicable

Exclusions and Limitations
More Included Benefits	Skilled Nursing Facility Allergy Testing Chemotherapy Radiation Diabetes Education Prosthetic Devices Infusion Therapy Treatment for Temporomandibular Joint Disorders Nutritional Counseling Other 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 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 Reconstructive Surgery
More Excluded Benefits	Long-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

Exclusions and Limitations

More Included Benefits

Skilled Nursing Facility
Allergy Testing
Chemotherapy
Radiation
Diabetes Education
Prosthetic Devices
Infusion Therapy
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Other 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
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
Reconstructive Surgery

More Excluded Benefits

Long-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

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