Base Catastrophic ST INN Dep25 Plan Details for 2021- HealthPocket

Base Catastrophic ST INN Dep25

$216.01/mo

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Zip Code11226
Applicant9/25/1986 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBase Catastrophic ST INN Dep25
Plan IDhhs-78124NY0910002
Plan Year2021
Insurance ProviderExcellus
Metal LevelCatastrophic
Plan TypeEPO
Deductible$8,550
Out-of-Pocket Maximum$8,550
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 ServicesNo Charge after deductible
X-rays and Diagnostic ImagingNo Charge after deductible
Diagnostic Imaging such as MRIs, CT, and PET scansNo Charge after deductible
Deductible - Family$17100 per group
Out-of-Pocket Maximum - Family$17100 per group

Prescription drug coverage

Generic DrugsNo Charge after deductible
Preferred Brand DrugsNo Charge after deductible
Non-Preferred Brand DrugsNo Charge after deductible
Specialty DrugsNot Applicable

Access to doctors and hospitals

Provider directory URLhttps://www.excellusbcbs.com/wps/portal/xl/find-doctor/
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 - BlueCard Worldwide
Does this plan cover services outside the country?Yes - Emergency Services Only

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
Emergency Transportation or Ambulance ServiceNo Charge after deductible

Maternity

Prenatal and Postnatal CareNo Charge
Delivery and all inpatient services for maternity careNo Charge after deductible

Mental Health

Mental/Behavioral Health Outpatient ServicesNo Charge after deductible
Mental/Behavioral Health Inpatient ServicesNo Charge after deductible
Substance use disorder outpatient servicesNo Charge after deductible
Substance use disorder inpatient servicesNo Charge after deductible

Medical Management Programs

Does this plan offer a wellness program?Not Covered

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 CareNot Covered
Child Dental Coverage - Basic Dental CareNot Covered
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
Bariatric Surgery
Hearing Aids
Infertility Treatment
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
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
Eating Disorder Treatment
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 BenefitsSkilled Nursing Facility
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Hospice Services
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 BenefitsAcupuncture
Cosmetic Surgery
Long Term Care
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Dental Care - Adult
Nutritional Counseling
Frames & Lenses
Contact Lenses
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $185Oscar Secure Catastrophic, ST3PCP, INN, Pediatric Dental, Dep25$8,550.00Select
from $216Base Catastrophic ST INN Pediatric Dental Dep25$8,550.00Select
from $217HDHMO Non-Qualified 50, Catastrophic, ST, INN, Dep25$8,550.00Select
from $363iDirect Bronze MV NS OON IHC Network Dep25$8,550.00Select
from $367iDirect Bronze MV NS OON IHC Network Dep29$8,550.00Select
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  • Phone Number
    (718) 434-7545
  • Office Locations
    29 Newkirk Plz
    Brooklyn, NY 11226
29 Newkirk Plz Brooklyn NY, 11226
  • What is the Catastrophic Plan?

    Catastrophic health insurance is a type of medical coverage under the Affordable Care Act. This is a type of high-deductible health plan for people under 30 or those who qualify for a "hardship exemption."

  • How are Catastrophic 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. There is no actuarial value associated with catastrophic plans but other Obamacare metal plans pay a higher percentage of these costs.

  • How much does a Catastrophic Plan cost?

    The monthly premium for a Catastrophic 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 Catastrophic Plan premiums in your area.

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HealthPocket.com is a free information source. 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. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. While on our site, if you click on a plan or link, you may be directed to one of our partners who offers health insurance products. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.