Maine's Choice HSA HMO 5000

Individual Health Insurance (Obamacare)

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Maine's Choice HSA HMO 5000

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Monthly Cost

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Benefits & Coverage

Plan Name
Maine's Choice HSA HMO 5000
Plan Year
2018
Insurance Type
Individual Health Insurance (Obamacare)
Insurance Provider
Metal Level
Expanded Bronze
Out-of-Pocket Maximum
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness
30.00% Coinsurance after deductible
Specialist Visit
30.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
30.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
30.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans
30.00% Coinsurance after deductible
Deductible - Family
$10000 per group
Out-of-Pocket Maximum - Family
$13100 per group

Prescription drug coverage

Generic Drugs
$15 Copay after deductible
Preferred Brand Drugs
30.00% Coinsurance after deductible
Non-Preferred Brand Drugs
50.00% Coinsurance after deductible
Specialty Drugs
50.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URL
http://www.providerlookuponline.com/Harvardpilgrim/po7/Search.aspx
Does this plan have access to a national provider network?
No
Is a referral required to see a Specialist?
Yes - A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers
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
30.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
30.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
30.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service
30.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care
No Charge
Delivery and all inpatient services for maternity care
30.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services
30.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
30.00% Coinsurance after deductible
Substance use disorder outpatient services
30.00% Coinsurance after deductible
Substance use disorder inpatient services
30.00% 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?
Included

Vision Coverage

Routine Eye Exam for Children
Included
Eye Glasses for Children
Included
Routine Eye Exam for Adults
Included

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
Bariatric Surgery
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
Home Health Care Services
Durable Medical Equipment
Hospice Services
Applied Behavior Analysis Based Therapies
Diabetes Care Management
Inherited Metabolic Disorder - PKU
Abortion for Which Public Funding is Prohibited
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Well Baby Visits and Care
Autism Spectrum Disorders
Clinical Trials
Off Label Prescription Drugs
Prescription Drugs Other
Low Protein Foods
Retail Health Clinics
More Limited Benefits
Skilled Nursing Facility
Acupuncture
Hearing Aids
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Inpatient Rehabilitation Services
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Cardiac Rehabilitation
Early Intervention Services
Human Leukocyte Antigen Testing
More Excluded Benefits
Cosmetic Surgery
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Treatment for Temporomandibular Joint Disorders

What To Know

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

Physician Directory

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