Ambetter Essential Care 2 HSA (2021) + Vision Plan Details for 2021- HealthPocket

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County
Applicant Info
Applicant
Date of birth
//
Gender
male
female
Income
$

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Zip Code	79936 (edit)
Applicant	1/22/1986 Male (edit)

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Insurance Type	ACA (Obamacare)
Plan Name	Ambetter Essential Care 2 HSA (2021) + Vision
Plan ID	hhs-29418TX0150070
Plan Year	2021
Insurance Provider	Ambetter
Metal Level	Expanded Bronze
Plan Type	EPO
Deductible	$6,900
Out-of-Pocket Maximum	$6,900
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	No Charge after deductible
Specialist Visit	No Charge after deductible
Laboratory Outpatient and Professional Services	No Charge after deductible
X-rays and Diagnostic Imaging	No Charge after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans	No Charge after deductible
Deductible - Family	$13800 per group
Out-of-Pocket Maximum - Family	$13800 per group

Prescription drug coverage
Generic Drugs	No Charge after deductible
Preferred Brand Drugs	No Charge after deductible
Non-Preferred Brand Drugs	No Charge after deductible
Specialty Drugs	No Charge after deductible

Access to doctors and hospitals
Provider directory URL	https://providersearch.ambetterhealth.com/
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	No Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	No Charge after deductible
Inpatient Physician and Surgical Services	No Charge after deductible
Emergency Transportation or Ambulance Service	No Charge after deductible

Maternity
Prenatal and Postnatal Care	No Charge after deductible
Delivery and all inpatient services for maternity care	No Charge after deductible

Mental Health
Mental/Behavioral Health Outpatient Services	No Charge after deductible
Mental/Behavioral Health Inpatient Services	No Charge after deductible
Substance use disorder outpatient services	No Charge after deductible
Substance use disorder inpatient services	No Charge 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	Included

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 Hearing Aids 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 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) Mental/Behavioral Health Emergency Room Mental/Behavioral Health Emergency Transportation/Ambulance Mental/Behavioral Health ER Physician Fee Mental/Behavioral Health Outpatient Other Services Mental/Behavioral Health Urgent Care Substance Use Disorder Emergency Room Substance Use Disorder Emergency Transportation/Ambulance Substance Use Disorder ER Physician Fee Substance Use Disorder Outpatient Other Services Substance Use Disorder Urgent Care Telehealth and Virtual Care
More Limited Benefits	Skilled Nursing Facility Home Health Care Services Outpatient Rehabilitation Services Habilitation Services Chiropractic Care Eyeglasses for Adults
More Excluded Benefits	Acupuncture Bariatric Surgery Cosmetic Surgery Private-Duty Nursing Weight Loss Programs Dental Check-Up for Children Abortion for Which Public Funding is Prohibited Long-Term/Custodial Nursing Home Care

+ See All Coverage Details

Premium	Plan Name	Deductible
from $361	BSW Savers Bronze HMO H S A 006 ($0 Preventive Care and Preven	$6,900.00	Select
from $420	Ambetter Essential Care 2 HSA (2021)	$6,900.00	Select
from $425	Ambetter Essential Care 2 HSA (2021) + Vision	$6,900.00	Select
from $441	Ambetter Essential Care 2 HSA (2021) + Vision + Adult Dental	$6,900.00	Select
from $455	Oscar Silver Classic Copay ($3 Prescription List + Free 24/7 Vi	$7,000.00	Select

Last Name

Location/Distance

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Huma, Lodhi

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Maria, Cardenas

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Patricia, Azarcon-samonte

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Thomas, Hoffer

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Nathaniel, Griffith

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Eep Internal Medicine Pa

Stephanie, Moreno

915 Pediatrics Pllc

Isabel, Cano

Sun Psychiatry Pllc

Dc Gastro Konsult

Stephanie Gonzalez Dpm Pa

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Patricia, Montiel Mendez

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Grace, Rodriguez

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Irving, Palacios Y Trejo

Marisela, Gomez

Alyson, Martinez

Dawn, Sackett

Erin, Ginithan

Saranya, Gangupalli

Elena, Paul

Jose, Ruiz

Huma Lodhi, M.D.

Phone Number
(915) 225-3807
Office Locations
11351 James Watt Dr
El Paso, TX 79936

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ZIP Code
County
Applicant Info
Applicant
Date of birth
//
Gender
male
female
Income
$

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Ambetter Essential Care 2 HSA (2021) + Vision

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Benefits & Coverage

Costs for Medical Care

Prescription drug coverage

Access to doctors and hospitals

Hospital services

Maternity

Mental Health

Medical Management Programs

Vision Coverage

Child Dental Coverage

Adult Dental Coverage

Exclusions and Limitations

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