AultCare Silver 2500 Select No Pediatric Dental

Individual Health Insurance (Obamacare)

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Benefits & Coverage

Plan Name
AultCare Silver 2500 Select No Pediatric Dental
Plan Year
2017
Insurance Type
Individual Health Insurance (Obamacare)
Insurance Provider
Metal Level
Silver
Out-of-Pocket Maximum
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness
20.00% Coinsurance after deductible
Specialist Visit
20.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
20.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
20.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans
20.00% Coinsurance after deductible
Deductible - Family
$5000 per group
Out-of-Pocket Maximum - Family
$12700 per group

Prescription drug coverage

Generic Drugs
20.00% Coinsurance after deductible
Preferred Brand Drugs
20.00% Coinsurance after deductible
Non-Preferred Brand Drugs
20.00% Coinsurance after deductible
Specialty Drugs
20.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URL
http://www.aultcare.com/myProviders
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 Service Area coverage from a network provider would be provided according to the plan benefits. Out of Service Area coverage from a Non-Network provider would be covered at the Non-Network plan benefits and the member would be responsible for any amounts exceeding plan limitations.
Does this plan cover services outside the country?
Yes - Generally, we may pay for limited Emergency Services that are necessary when You are traveling out of the USA, unless you are expressly traveling on business on behalf of Your Employer. We will consider each Claim carefully. We will not pay for Services when You go to another Country to obtain medical care. We do not pay for air transport or medical evacuation. We recommend that You obtain separate medical travel and evacuation insurance if You Plan to travel out of the USA.

Hospital services

Emergency Room Services
20.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
20.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
20.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service
20.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care
20.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care
20.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services
20.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
20.00% Coinsurance after deductible
Substance use disorder outpatient services
20.00% Coinsurance after deductible
Substance use disorder inpatient services
20.00% Coinsurance 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 Children
Included
Eye Glasses for Children
Included
Routine Eye Exam for Adults
Not Covered

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
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
Habilitation Services
Durable Medical Equipment
Hospice Services
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
More Limited Benefits
Skilled Nursing Facility
Private-Duty Nursing
Home Health Care Services
Outpatient Rehabilitation Services
Chiropractic Care
Accidental Dental
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded Benefits
Acupuncture
Bariatric Surgery
Cosmetic Surgery
Hearing Aids
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Abortion for Which Public Funding is Prohibited

What To Know

  • This is an ACA (Obamacare) compliant health plan.

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