2018 18 IF HMO 50-NA 0000 P D7350X2 Plan Details - HealthPocket

18 IF HMO 50-NA 0000 P D7350X2

$403.02/mo

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Zip Code89110
Applicant10/18/1983 Male
Coverage Start10/20/2018
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan Name18 IF HMO 50-NA 0000 P D7350X2
Plan IDhhs-41094NV0030060
Plan Year2018
Insurance ProviderHOMETOWN HEALTH PLAN, INC
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$7,350
Out-of-Pocket Maximum$7,350
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$50 Copay
Specialist Visit$100 Copay
Laboratory Outpatient and Professional Services$40 Copay
X-rays and Diagnostic Imaging$100 Copay
Diagnostic Imaging such as MRIs, CT, and PET scans$0 Copay after deductible
Deductible - Family$14700 per group
Out-of-Pocket Maximum - Family$14700 per group

Prescription drug coverage

Generic Drugs$30 Copay
Preferred Brand Drugs$90 Copay
Non-Preferred Brand Drugs$140 Copay
Specialty Drugs100.00% Coinsurance

Access to doctors and hospitals

Provider directory URLhttps://apps.hometownhealth.com/OnlineProviderDirectory/
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Yes - All except OBGYN
Does this plan cover services outside plan service area?Yes - Emergencies and urgent care only outside of Nevada
Does this plan cover services outside the country?Yes - Emergencies Only

Hospital services

Emergency Room Services$0 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)Not Applicable
Inpatient Physician and Surgical Services$0 Copay after deductible
Emergency Transportation or Ambulance Service$0 Copay after deductible

Maternity

Prenatal and Postnatal Care$0 Copay
Delivery and all inpatient services for maternity care$0 Copay after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$50 Copay
Mental/Behavioral Health Inpatient Services$0 Copay after deductible
Substance use disorder outpatient services$50 Copay
Substance use disorder inpatient services$0 Copay 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
Private-Duty Nursing
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
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Radiation
Reconstructive Surgery
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
More Limited BenefitsSkilled Nursing Facility
Acupuncture
Bariatric Surgery
Hearing Aids
Infertility Treatment
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Hospice Services
Dental Check-Up for Children
Chiropractic Care
Nutritional Counseling
Prosthetic Devices
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsCosmetic Surgery
Long-Term/Custodial Nursing Home Care
Weight Loss Programs
Routine Foot Care
Abortion for Which Public Funding is Prohibited
PremiumPlan NameDeductible
from $200
MyHPN Catastrophic Plan
$7,350.00Select
from $228
Anthem Catastrophic Pathway PPO 7350
$7,350.00Select
from $231
MySHL Solutions EPO Catastrophic 1
$7,350.00Select
from $236
MySHL Solutions PPO Catastrophic 1
$7,350.00Select
from $239
Anthem Catastrophic Pathway HMO 7350
$7,350.00Select

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