Gold Select NS INN Dep25 Acupuncture Plan Details for 2021- HealthPocket

Insurance Type	ACA (Obamacare)
Plan Name	Gold Select NS INN Dep25 Acupuncture
Plan ID	hhs-78124NY0890016
Plan Year	2021
Insurance Provider	Excellus
Metal Level	Gold
Plan Type	EPO
Deductible	$750
Out-of-Pocket Maximum	$8,000
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	$25 Copay after deductible
Specialist Visit	$40 Copay after deductible
Laboratory Outpatient and Professional Services	$40 Copay after deductible
X-rays and Diagnostic Imaging	$40 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans	$100 Copay after deductible
Deductible - Family	$1500 per group
Out-of-Pocket Maximum - Family	$16000 per group

Prescription drug coverage
Generic Drugs	$10 Copay
Preferred Brand Drugs	$35 Copay
Non-Preferred Brand Drugs	$70 Copay
Specialty Drugs	Not Applicable

Access to doctors and hospitals
Provider directory URL	https://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 Services	$350 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	$1000 Copay per Stay after deductible
Inpatient Physician and Surgical Services	Not Applicable
Emergency Transportation or Ambulance Service	$350 Copay after deductible

Maternity
Prenatal and Postnatal Care	Not Applicable
Delivery and all inpatient services for maternity care	$1000 Copay after deductible

Mental Health
Mental/Behavioral Health Outpatient Services	$25 Copay after deductible
Mental/Behavioral Health Inpatient Services	$1000 Copay per Stay after deductible
Substance use disorder outpatient services	$25 Copay after deductible
Substance use disorder inpatient services	$1000 Copay per Stay after deductible

Medical Management Programs
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 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 Benefits	Skilled Nursing Facility Acupuncture 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 Benefits	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

+ See All Coverage Details

Premium	Plan Name	Deductible
from $234	Fidelis Care Gold for Children, Child Only, ST, INN, Fidelis Ca	$600.00	Select
from $268	Standard Gold Child Only ST OON IHC Network	$600.00	Select
from $304	Healthfirst Gold Leaf, Child-Only, ST, INN, Pediatric Dental, F	$600.00	Select
from $348	HMO Copayment 20, Gold Child Only, ST, INN	$600.00	Select
from $355	Gold Standard Child Only ST INN	$600.00	Select

Last Name

Location/Distance

Please select the correct zip

Geo Medical Care P.c.

Steven, Liverpool

Sabu, John

Eric, Muniz

Marie, Normil

Akua, Boah

Mathieu, Francois

Emily, Wang

Osama, Marie

Lourdes, Rodriguez

Church Medical Offices

Hellena, Slade

Ashley, Salinas

Francesca, Pinto

Rachel, Golub

Tiffany, Santiago

Civil Physical Therapy, Pllc

Srushti, Gambhire

Kandice, Harper

Randy, Singh

Anastasia, Agababyan

Hoiman, Poon

Iryna, Leskiv

Maryanne, Cai

Cassandre, Fecu

Geo Medical Care P.c.

View All Details

Phone Number
(718) 434-7545
Office Locations
29 Newkirk Plz
Brooklyn, NY 11226

What is the Gold Plan?
ObamaCare’s Gold Plan is a type of Metal Plan on the Health Insurance Marketplace. Gold Plans qualify for Tax Credits, have high premiums, and good cost sharing. Gold plans mean higher premiums, less Tax Credits, but much better cost sharing on average than Silver or Bronze.
How are Gold 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 Gold Plan typically pays 80% of covered medical costs.
How much does a Gold Plan cost?
The monthly premium for a Gold 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 your geographic region. You can use HealthPocket’s comparison tool to compare Gold Plan premiums in your area.
When Can I Enroll in a Gold 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.

Zip Code	11226 (edit)
Applicant	1/18/1986 Male (edit)

Zip Code	11226 (edit)
Applicant	1/18/1986 Male (edit)

Gold Select NS INN Dep25 Acupuncture

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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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