2018 Empire EPO 0 Platinum ST INN Pediatric Dental Dep 29 SNF Plan Details - HealthPocket

Empire EPO 0 Platinum ST INN Pediatric Dental Dep 29 SNF

$1,166.20/mo

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Zip Code11226
Applicant8/21/1983 Male
Coverage Start8/23/2018
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameEmpire EPO 0 Platinum ST INN Pediatric Dental Dep 29 SNF
Plan IDhhs-44113NY0560122
Insurance ProviderEmpire
Metal LevelPlatinum
Plan TypeEPO
Deductible$0
Out-of-Pocket Maximum$2,000
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$15 Copay
Specialist Visit$35 Copay
Laboratory Outpatient and Professional Services$35 Copay
X-rays and Diagnostic Imaging$35 Copay
Diagnostic Imaging such as MRIs, CT, and PET scans$35 Copay
Deductible - Family$0 per group
Out-of-Pocket Maximum - Family$4000 per group

Prescription drug coverage

Generic Drugs$10 Copay
Preferred Brand Drugs$30 Copay
Non-Preferred Brand Drugs$60 Copay
Specialty DrugsNot Applicable

Access to doctors and hospitals

Provider directory URLhttp://www.empireblue.com
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?No - TRAD/PAR network
Does this plan cover services outside the country?No - Emergency Coverage Only

Hospital services

Emergency Room Services$100 Copay
Inpatient Hospital Services (e.g., Hospital Stay)$500 Copay per Stay
Inpatient Physician and Surgical Services$100 Copay
Emergency Transportation or Ambulance Service$100 Copay

Maternity

Prenatal and Postnatal CareNo Charge
Delivery and all inpatient services for maternity care$600 Copay

Mental Health

Mental/Behavioral Health Outpatient Services$15 Copay
Mental/Behavioral Health Inpatient Services$500 Copay per Stay
Substance use disorder outpatient services$15 Copay
Substance use disorder inpatient services$500 Copay per Stay

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
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
Bariatric Surgery
Infertility Treatment
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
Durable Medical Equipment
Chiropractic Care
Applied Behavior Analysis Based Therapies
Cochlear Implants
Second Opinion
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Breast Reconstructive Surgery
Cardiac Rehabilitation
Prostate Cancer Screening
Assistive Communication Devices
Autologous Blood Banking
Gym Membership Reimbursement
Medical Supplies
Preadmission Testing
Design
Diabetic Equipment and Supplies
Family Planning Services
Sterilization Procedures for Men
More Limited BenefitsSkilled Nursing Facility
Hearing Aids
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Hospice Services
Dental Check-Up for Children
Inpatient Rehabilitation Services
Abortion for Which Public Funding is Prohibited
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Contact Lenses for Children
More Excluded BenefitsAcupuncture
Cosmetic Surgery
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Routine Foot Care
Nutritional Counseling
PremiumPlan NameDeductible
from $1,025
MVP Premier POS Platinum ST OON Dep25 Telemedicine Wellness
$0.00Select
from $1,035
MVP Premier POS Platinum ST OON Dep29 Telemedicine Wellness
$0.00Select
from $1,055
MVP Premier POS Platinum ST OON Dep25 SNF Telemedicine Wellness
$0.00Select
from $1,066
MVP Premier POS Platinum ST OON Dep29 SNF Telemedicine Wellness
$0.00Select
from $1,110
EmblemHealth Platinum, Platinum, ST, INN, Pediatric Dental, Dep
$0.00Select
  • What is the Platinum Plan?

    ObamaCare’s Platinum Plan is a type of Metal Plan on the Health Insurance Marketplace. Platinum Plans qualify for Tax Credits and have the highest premiums. A Platinum Plan is designed to incur the lowest out-of-pocket expenses for enrollees. A typical platinum plan enrollee pays approximately 10% of the costs of covered healthcare services with the plan paying the remainder. In comparison, a typical Bronze Plan enrollee pays 40% of covered medical expenses.

  • How are Platinum 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 Platinum Plan pays 90% of covered medical costs for a typical enrollee while the other Obamacare health plans pay a lower percentage of these costs.

  • How much does a Platinum Plan cost?

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

  • When Can I Enroll in a Platinum 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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