2018 Conversion Plan 1 Plan Details - HealthPocket

Conversion Plan 1

$564.12/mo

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Zip Code55106
Applicant8/18/1983 Male
Coverage Start8/19/2018
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameConversion Plan 1
Plan IDhhs-88102MN0200001
Insurance ProviderPreferredOne Insurance Company
Metal LevelGold
Plan TypePPO
Deductible$1,000
Out-of-Pocket Maximum$3,000
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness20.00% Coinsurance after deductible
Specialist Visit20.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services20.00% Coinsurance after deductible
X-rays and Diagnostic Imaging20.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans20.00% Coinsurance after deductible
Deductible - Family$3000 per group
Out-of-Pocket Maximum - Family$5000 per group

Prescription drug coverage

Generic Drugs20.00% Coinsurance after deductible
Preferred Brand Drugs20.00% Coinsurance after deductible
Non-Preferred Brand Drugs20.00% Coinsurance after deductible
Specialty Drugs20.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttp://providerguide.preferredone.com/Default.asp?Network=OA300
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 - Out of network benefits apply
Does this plan cover services outside the country?Yes - Emergency Only

Hospital services

Emergency Room Services20.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)20.00% Coinsurance after deductible
Inpatient Physician and Surgical Services20.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service20.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal CareNo Charge
Delivery and all inpatient services for maternity care20.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services20.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services20.00% Coinsurance after deductible
Substance use disorder outpatient services20.00% Coinsurance after deductible
Substance use disorder inpatient services20.00% 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?Included

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsIncluded

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
Acupuncture
Cosmetic Surgery
Weight Loss Programs
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Chiropractic Care
Routine Foot Care
Dental Anesthesia
Diabetes Care Management
Inherited Metabolic Disorder - PKU
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Congenital Anomaly, including Cleft Lip/Palate
Off Label Prescription Drugs
Port-Wine Stain Removal
Prescription Drugs Other
Residential Treatment for Children with Emotional Disabilities
Services to Ventilator-Dependent Persons
Treatment of Lyme Disease
Genetic Testing
Biofeedback
Infertility Diagnosis
Routine Patient Cost for Clinical Trials
Lyme Disease
Mental Health Disorder
Phenylketonuria Dietary Treatment
Testing for STD's
Treatment for STD's
Treatment for children with Emotional Disabilities
More Limited BenefitsSkilled Nursing Facility
Hearing Aids
Private-Duty Nursing
Inpatient Physician and Surgical Services
Hospice Services
Dental Check-Up for Children
More Excluded BenefitsBariatric Surgery
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Abortion for Which Public Funding is Prohibited
PremiumPlan NameDeductible
from $75
Everest 1000/20/5000/250000
$1,000.00Select
from $76
Everest 1000/20/4000/250000
$1,000.00Select
from $79
Everest 1000/20/3000/250000
$1,000.00Select
from $85
LifeShield Flex 1000/20/5000/750000
$1,000.00Select
from $87
Everest 1000/20/5000/1000000
$1,000.00Select
  • 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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