Insurance Type | ACA (Obamacare) |
Plan Name | Standard High Bronze: UHC Navigate HSA Bronze 3600 |
Plan ID | hhs-31779MA0110005 |
Plan Year | 2021 |
Insurance Provider | Golden Rule Insurance |
Metal Level | Expanded Bronze |
Plan Type | EPO |
Deductible | $3,600 |
Out-of-Pocket Maximum | $7,000 |
Plan Highlights |
Costs for Medical Care | |
---|---|
Primary Care Visit to Treat an Injury or Illness | $100 Copay after deductible |
Specialist Visit | $150 Copay after deductible |
Laboratory Outpatient and Professional Services | $55 Copay after deductible |
X-rays and Diagnostic Imaging | $140 Copay after deductible |
Diagnostic Imaging such as MRIs, CT, and PET scans | $1000 Copay after deductible |
Deductible - Family | $7200 per group |
Out-of-Pocket Maximum - Family | $14000 per group |
Prescription drug coverage | |
---|---|
Generic Drugs | $30 Copay after deductible |
Preferred Brand Drugs | $150 Copay after deductible |
Non-Preferred Brand Drugs | $225 Copay after deductible |
Specialty Drugs | $225 Copay after deductible |
Access to doctors and hospitals | |
---|---|
Provider directory URL | http://bitly.com/uhcfad |
Does this plan have access to a national provider network? | No |
Is a referral required to see a Specialist? | Yes - Yes, enter All, except OBGYN and as state mandated |
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 | $1750 Copay after deductible |
Inpatient Hospital Services (e.g., Hospital Stay) | $2000 Copay per Stay after deductible |
Inpatient Physician and Surgical Services | No Charge after deductible |
Emergency Transportation or Ambulance Service | Not Applicable |
Maternity | |
---|---|
Prenatal and Postnatal Care | No Charge |
Delivery and all inpatient services for maternity care | $2000 Copay after deductible |
Mental Health | |
---|---|
Mental/Behavioral Health Outpatient Services | $100 Copay after deductible |
Mental/Behavioral Health Inpatient Services | $2000 Copay per Stay after deductible |
Substance use disorder outpatient services | $100 Copay after deductible |
Substance use disorder inpatient services | $2000 Copay per Stay after deductible |
Medical Management Programs | |
---|---|
Does this plan offer disease managment programs? | 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 | Not Covered |
Child Dental Coverage | |
---|---|
Child Dental Coverage - Routine Dental Care | Included |
Child Dental Coverage - Basic Dental Care | Included |
Child Dental Coverage - Orthodontia | Included |
Child Dental Coverage - Major Dental Care | Included |
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 Infertility Treatment 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 Chiropractic Care Abortion for Which Public Funding is Prohibited Allergy Testing Chemotherapy Diabetes Education Dialysis Infusion Therapy Laboratory Outpatient and Professional Services Nutritional Counseling Prosthetic Devices Radiation Reconstructive Surgery Rehabilitative Speech Therapy Transplant Treatment for Temporomandibular Joint Disorders Well Baby Visits and Care Outpatient Facility Fee (e.g., Ambulatory Surgery Center) |
More Limited Benefits | Skilled Nursing Facility Hearing Aids Weight Loss Programs Outpatient Rehabilitation Services Habilitation Services Dental Check-Up for Children Rehabilitative Occupational and Rehabilitative Physical Therapy |
More Excluded Benefits | Acupuncture Cosmetic Surgery Private-Duty Nursing Routine Foot Care Accidental Dental Long-Term/Custodial Nursing Home Care |
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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.
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