2018 Empire EPO 600 Gold ST INN Pediatric Dental Dep 29 SNF Plan Details - HealthPocket

Empire EPO 600 Gold ST INN Pediatric Dental Dep 29 SNF

$977.45/mo

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Zip Code11226
Applicant10/23/1983 Male
Coverage Start10/25/2018
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameEmpire EPO 600 Gold ST INN Pediatric Dental Dep 29 SNF
Plan IDhhs-44113NY0560118
Plan Year2018
Insurance ProviderEmpire
Metal LevelGold
Plan TypeEPO
Deductible$600
Out-of-Pocket Maximum$4,000
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$25 Copay after deductible
Specialist Visit$40 Copay after deductible
Laboratory Outpatient and Professional Services$40 Copay after deductible
X-rays and Diagnostic Imaging$40 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans$40 Copay after deductible
Deductible - Family$1200 per group
Out-of-Pocket Maximum - Family$8000 per group

Prescription drug coverage

Generic Drugs$10 Copay
Preferred Brand Drugs$35 Copay
Non-Preferred Brand Drugs$70 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$150 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)$1000 Copay per Stay after deductible
Inpatient Physician and Surgical Services$100 Copay after deductible
Emergency Transportation or Ambulance Service$150 Copay after deductible

Maternity

Prenatal and Postnatal CareNo Charge
Delivery and all inpatient services for maternity care$1100 Copay after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$25 Copay after deductible
Mental/Behavioral Health Inpatient Services$1000 Copay per Stay after deductible
Substance use disorder outpatient services$25 Copay after deductible
Substance use disorder inpatient services$1000 Copay per Stay 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
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 $262
MVP Premier Gold Child Only ST INN Telemedicine Wellness
$600.00Select
from $264
MVP Premier Gold 2 Child Only ST3PCP INN Telemedicine Wellness
$650.00Select
from $270
MVP Premier Gold Child Only ST INN SNF Telemedicine Wellness
$600.00Select
from $272
MVP Premier Gold 2 Child Only ST3PCP INN SNF Telemedicine Welln
$650.00Select
from $276
Standard Gold Child Only ST OON Dep25
$600.00Select
  • What is the Gold Plan?

    ObamaCare’s Gold Plan is a type of Metal Plan on the Health Insurance Marketplace. Gold Plans qualify for Tax Credits, have high premiums, and good cost sharing. Gold plans mean higher premiums, less Tax Credits, but much better cost sharing on average than Silver or Bronze.

  • How are Gold 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 Gold Plan typically pays 80% of covered medical costs.

  • How much does a Gold Plan cost?

    The monthly premium for a Gold 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 your geographic region. You can use HealthPocket’s comparison tool to compare Gold Plan premiums in your area.

  • When Can I Enroll in a Gold 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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