SmartChoice Silver 4000 Plan Details for 2021- HealthPocket

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Zip Code97229
Applicant7/31/1986 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameSmartChoice Silver 4000
Plan IDhhs-10091OR0750008
Plan Year2021
Insurance ProviderPacificSource Health Plans
Metal LevelSilver
Plan TypePPO
Deductible$4,000
Out-of-Pocket Maximum$7,900
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$20 Copay
Specialist Visit$40 Copay
Laboratory Outpatient and Professional Services30.00% Coinsurance after deductible
X-rays and Diagnostic Imaging30.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans30.00% Coinsurance after deductible
Deductible - Family$8000 per group
Out-of-Pocket Maximum - Family$15800 per group

Prescription drug coverage

Generic Drugs30.00% Coinsurance after deductible
Preferred Brand Drugs30.00% Coinsurance after deductible
Non-Preferred Brand Drugs30.00% Coinsurance after deductible
Specialty Drugs30.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttps://www.pacificsource.com/find-a-provider/
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 - In and out-of-network providers
Does this plan cover services outside the country?Yes - Emergency Care Only

Hospital services

Emergency Room Services30.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)30.00% Coinsurance after deductible
Inpatient Physician and Surgical Services30.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service30.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care30.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care30.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$20 Copay
Mental/Behavioral Health Inpatient Services30.00% Coinsurance after deductible
Substance use disorder outpatient services$20 Copay
Substance use disorder inpatient services30.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes, Heart Disease, Pregnancy
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 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
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Home Health Care Services
Durable Medical Equipment
Hospice Services
Routine Foot Care
Abortion for Which Public Funding is Prohibited
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Well Baby Visits and Care
Telehealth
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Tier 1 - Zero Cost-Share Preventive Drugs
Tier 2 - Preferred Generic Drugs
Tier 3 - Non-Preferred Generic Drugs
Tier 4 - Preferred Brand Drugs
Tier 5 - Non-Preferred Brand Drugs
Tier 6 - Preferred Specialty Drugs
Tier 7 - Non-Preferred Specialty Drugs
More Limited BenefitsSkilled Nursing Facility
Acupuncture
Cosmetic Surgery
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsBariatric Surgery
Infertility Treatment
Long Term Care
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Dental Care - Adult
Treatment for Temporomandibular Joint Disorders
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $395Alliance Silver Care on Demand 4000 EPO Legacy LHP$4,000.00Select
from $404Silver Care on Demand 4000 EPO OHSU Health$4,000.00Select
from $416Silver Care on Demand 4000 EPO Individual and Family Network$4,000.00Select
from $444Navigator Silver 4000$4,000.00Select
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  • Phone Number
    (503) 629-0237
  • Office Locations
    14223 Nw Spruceridge Ln
    Portland, OR 97229
14223 Nw Spruceridge Ln Portland OR, 97229
  • What Is the Silver Plan?

    ObamaCare’s Silver Plan is a type of Metal Plan on the Health Insurance Marketplace. Silver Plans qualify for both Tax Credits and Cost Sharing subsidies.Silver Plans have lower out-of-pocket costs than Bronze Plans but higher out- of-pocket costs than both Gold and Platinum Plans. All Silver Plans share the same minimum health benefits, but the way they charge out-of-pocket costs can differ significantly.

  • How are Silver 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 Silver Plan pays 70% of covered medical costs for a typical enrollee. Silver Plans are also the only metal plans which offer cost-sharing reduction (CSR) versions to consumers that require financial assistance for out-of-pocket costs.

  • How much does a Silver Plan cost?

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

  • When Can I Enroll in a Silver 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.