Value Bronze Saver (HSA) Plan Details for 2021- HealthPocket

Value Bronze Saver (HSA)

$380.13/mo

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Zip Code37013
Applicant9/22/1986 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameValue Bronze Saver (HSA)
Plan IDhhs-69443TN0140005
Plan Year2021
Insurance ProviderGolden Rule Insurance
Metal LevelExpanded Bronze
Plan TypeEPO
Deductible$5,900
Out-of-Pocket Maximum$7,000
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness30.00% Coinsurance after deductible
Specialist Visit30.00% Coinsurance after deductible
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$11800 per group
Out-of-Pocket Maximum - Family$14000 per group

Prescription drug coverage

Generic Drugs$20 Copay 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 URLhttp://www.uhc.com/find-a-physician
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Yes - 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 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 CareNot Applicable
Delivery and all inpatient services for maternity care30.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services30.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services30.00% Coinsurance after deductible
Substance use disorder outpatient services30.00% Coinsurance after deductible
Substance use disorder inpatient services30.00% Coinsurance 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 CareIncluded
Child Dental Coverage - Basic Dental CareIncluded
Child Dental Coverage - OrthodontiaIncluded
Child Dental Coverage - Major Dental CareIncluded

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
Durable Medical Equipment
Hospice Services
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
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
Outpatient Rehabilitation Services
Habilitation Services
Dental Check-Up for Children
Chiropractic Care
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsAcupuncture
Bariatric Surgery
Cosmetic Surgery
Infertility Treatment
Private-Duty Nursing
Weight Loss Programs
Routine Foot Care
Abortion for Which Public Funding is Prohibited
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $347Bronze B07L, Network L$5,950.00Select
from $357Cigna Connect 5900$5,900.00Select
from $379Bronze 5900 Direct$5,900.00Select
from $412Cigna Connect 5750$5,750.00Select
from $435Bronze B07S, Network S$5,950.00Select
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  • Phone Number
    (615) 941-8501
  • Office Locations
    5801 Crossings Blvd
    Antioch, TN 37013
5801 Crossings Blvd Antioch TN, 37013

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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.