Individual HMO Platinum w/Gym Membership Plan Details for 2020- HealthPocket

Individual HMO Platinum w/Gym Membership

$880.01/mo

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Zip Code87121
Applicant4/6/1985 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameIndividual HMO Platinum w/Gym Membership
Plan IDhhs-57173NM0200001
Plan Year2020
Insurance ProviderPresbyterian
Metal LevelPlatinum
Plan TypeHMO
Deductible$100
Out-of-Pocket Maximum$6,650
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$5 Copay
Specialist Visit$20 Copay
Laboratory Outpatient and Professional ServicesNot Applicable
X-rays and Diagnostic ImagingNot Applicable
Diagnostic Imaging such as MRIs, CT, and PET scans$50 Copay
Deductible - Family$200 per group
Out-of-Pocket Maximum - Family$13300 per group

Prescription drug coverage

Generic Drugs$5 Copay
Preferred Brand Drugs$10 Copay
Non-Preferred Brand Drugs$75 Copay
Specialty Drugs20.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttp://www.phs.org/directory
Does this plan have access to a national provider network?Yes
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?Yes - Emergency and Non-Emergency whe Prior Authorization is obtained.
Does this plan cover services outside the country?Yes - Emergency and Non-Emergency whe Prior Authorization is obtained.

Hospital services

Emergency Room Services$100 Copay
Inpatient Hospital Services (e.g., Hospital Stay)20.00% Coinsurance after deductible
Inpatient Physician and Surgical Services20.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service20.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care$300 Copay
Delivery and all inpatient services for maternity care20.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$5 Copay
Mental/Behavioral Health Inpatient Services20.00% Coinsurance after deductible
Substance use disorder outpatient services$5 Copay
Substance use disorder inpatient services20.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol
Does this plan offer a wellness program?Included

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareIncluded
Child Dental Coverage - Basic Dental CareIncluded
Child Dental Coverage - OrthodontiaNot Covered
Child Dental Coverage - Major Dental CareNot Covered

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Skilled Nursing Facility
Infertility Treatment
Weight Loss Programs
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
Dental Check-Up for Children
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
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 BenefitsAcupuncture
Bariatric Surgery
Hearing Aids
Home Health Care Services
Chiropractic Care
Prosthetic Devices
More Excluded BenefitsCosmetic Surgery
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Foot Care
Abortion for Which Public Funding is Prohibited
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  • Phone Number
    (505) 831-2534
  • Office Locations
    6900 Gonzales Rd Sw
    Albuquerque, NM 87121
6900 Gonzales Rd Sw Albuquerque NM, 87121
  • What is the Platinum Plan?

    ObamaCare’s Platinum Plan is a type of Metal Plan on the Health Insurance Marketplace. Platinum Plans qualify for Tax Credits and have the highest premiums. A Platinum Plan is designed to incur the lowest out-of-pocket expenses for enrollees. A typical platinum plan enrollee pays approximately 10% of the costs of covered healthcare services with the plan paying the remainder. In comparison, a typical Bronze Plan enrollee pays 40% of covered medical expenses.

  • How are Platinum Plans different than other Obamacare health plans?

    The fundamental difference among the new Obamacare health plans is the percentage of covered medical costs paid by the health plan. The Platinum Plan pays 90% of covered medical costs for a typical enrollee while the other Obamacare health plans pay a lower percentage of these costs.

  • How much does a Platinum Plan cost?

    The monthly premium for a Platinum 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 the region in which you live. You can use HealthPocket’s comparison tool to compare Platinum Plan premiums in your area.

  • When Can I Enroll in a Platinum Plan?

    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.

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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).

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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 Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).