Medica Symphony for HSA Gold G Plan Details for 2021- HealthPocket

Medica Symphony for HSA Gold G

$441.72/mo

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Zip Code55106
Applicant7/31/1986 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameMedica Symphony for HSA Gold G
Plan IDhhs-31616MN0200015
Plan Year2021
Insurance ProviderMedica
Metal LevelGold
Plan TypePPO
Deductible$3,000
Out-of-Pocket Maximum$3,000
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$6000 per group
Out-of-Pocket Maximum - Family$6000 per group

Prescription drug coverage

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

Access to doctors and hospitals

Provider directory URLhttp://www.medica.com/FindADoctor/IndividualandFamilyPlanMembers/default.aspx
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?Yes - Out of Network Benefits
Does this plan cover services outside the country?Yes - Emergency Services

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 after deductible
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 disease managment programs?Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss 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 AdultsIncluded

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
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
Chiropractic 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)
More Limited BenefitsSkilled Nursing Facility
Hearing Aids
Home Health Care Services
More Excluded BenefitsAcupuncture
Bariatric Surgery
Cosmetic Surgery
Infertility Treatment
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Abortion for Which Public Funding is Prohibited
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $322Blue Plus Minnesota Value Silver $3200 Plan 204$3,200.00Select
from $364Medica Solo Silver A$3,200.00Select
from $436Select Gold I403 HSA DIRECT$3,000.00Select
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  • Phone Number
    (651) 793-3100
  • Office Locations
    651 Arcade St
    Saint Paul, MN 55106
651 Arcade St Saint Paul MN, 55106
  • 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.

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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.