Totally You

Individual Health Insurance (Obamacare)

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Benefits & Coverage
Plan Name
Totally You
Plan Year
2016
Insurance Type
Individual Health Insurance (Obamacare)
Insurance Provider
Metal Level
Silver
Out-of-Pocket Maximum
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness
$20 Copay
Specialist Visit
$40 Copay
Laboratory Outpatient and Professional Services
20% Coinsurance after deductible
X-rays and Diagnostic Imaging
20% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans
20% Coinsurance after deductible
Deductible - Family
$6000 per group
Out-of-Pocket Maximum - Family
$10000 per group

Prescription drug coverage

Generic Drugs
$25 Copay
Preferred Brand Drugs
$50 Copay
Non-Preferred Brand Drugs
$100 Copay
Specialty Drugs
50% Coinsurance

Access to doctors and hospitals

Provider directory URL
http://www.thcmi.com
Does this plan have access to a national provider network?
No
Is a referral required to see a Specialist?
Yes - Podiatry, Chiropractic
Does this plan cover services outside plan service area?
Yes - Emergency
Does this plan cover services outside the country?
Yes - Emergency

Hospital services

Emergency Room Services
20% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
20% Coinsurance after deductible
Inpatient Physician and Surgical Services
20% Coinsurance after deductible
Emergency Transportation or Ambulance Service
$75 Copay

Maternity

Prenatal and Postnatal Care
No Charge
Delivery and all inpatient services for maternity care
20% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services
$40 Copay
Mental/Behavioral Health Inpatient Services
20% Coinsurance after deductible
Substance use disorder outpatient services
$40 Copay
Substance use disorder inpatient services
20% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?
Asthma, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs
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
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
Cosmetic Surgery
Infertility Treatment
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
Inpatient Physician and Surgical Services
Habilitation Services
Durable Medical Equipment
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
Mental Health - Other
Prescription Drugs - Other
More Limited Benefits
Skilled Nursing Facility
Bariatric Surgery
Hearing Aids
Home Health Care Services
Outpatient Rehabilitation Services
Hospice Services
Chiropractic Care
Nutritional Counseling
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Cardiac Rehabilitation
Eyeglasses for Adults
More Excluded Benefits
Acupuncture
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Dental Check-Up for Children
Routine Foot Care
Non-Emergency Care When Traveling Outside the U.S.
Abortion for Which Public Funding is Prohibited

What To Know

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