MVP Premier Plus Bronze 2 NS INN Dep29 Acupuncture Telemedicine
$528.34/mo
Apply For This Plan
| Zip Code | 11226 |
| Applicant | 11/16/1983 Male |
| Coverage Start | 11/19/2018 |
Benefits & Coverage
| Insurance Type | ACA (Obamacare) |
| Plan Name | MVP Premier Plus Bronze 2 NS INN Dep29 Acupuncture Telemedicine |
| Plan ID | hhs-56184NY0150008 |
| Plan Year | 2018 |
| Insurance Provider | MVP |
| Metal Level | Expanded Bronze |
| Plan Type | HMO |
| Deductible | $5,100 |
| Out-of-Pocket Maximum | $7,150 |
| Plan Highlights |
Costs for Medical Care | |
|---|---|
| Primary Care Visit to Treat an Injury or Illness | 40.00% Coinsurance after deductible |
| Specialist Visit | 40.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | 40.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging | 40.00% Coinsurance after deductible |
| Diagnostic Imaging such as MRIs, CT, and PET scans | 40.00% Coinsurance after deductible |
| Deductible - Family | $10200 per group |
| Out-of-Pocket Maximum - Family | $14300 per group |
Prescription drug coverage | |
|---|---|
| Generic Drugs | $5 Copay after deductible |
| Preferred Brand Drugs | $60 Copay after deductible |
| Non-Preferred Brand Drugs | $80 Copay after deductible |
| Specialty Drugs | Not Applicable |
Access to doctors and hospitals | |
|---|---|
| Provider directory URL | https://www.mvphealthcare.com/members/find-a-doctor/ |
| 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 - Emergency Only |
| Does this plan cover services outside the country? | Yes - Emergency Only |
Hospital services | |
|---|---|
| Emergency Room Services | 40.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay) | 40.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 40.00% Coinsurance after deductible |
| Emergency Transportation or Ambulance Service | 40.00% Coinsurance after deductible |
Maternity | |
|---|---|
| Prenatal and Postnatal Care | Not Applicable |
| Delivery and all inpatient services for maternity care | 40.00% Coinsurance after deductible |
Mental Health | |
|---|---|
| Mental/Behavioral Health Outpatient Services | 40.00% Coinsurance after deductible |
| Mental/Behavioral Health Inpatient Services | 40.00% Coinsurance after deductible |
| Substance use disorder outpatient services | 40.00% Coinsurance after deductible |
| Substance use disorder inpatient services | 40.00% Coinsurance after deductible |
Medical Management Programs | |
|---|---|
| Does this plan offer disease managment programs? | Asthma, Depression, Diabetes, Heart Disease, Low Back Pain, Pregnancy |
| 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 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 Telemedicine |
| More Limited Benefits | Skilled Nursing Facility Acupuncture Hearing Aids Home Health Care Services Outpatient Rehabilitation Services Habilitation Services Hospice Services 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 Benefits | Cosmetic Surgery Long-Term/Custodial Nursing Home Care Private-Duty Nursing Weight Loss Programs Dental Check-Up for Children Routine Foot Care Nutritional Counseling |
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