— Plan Health Benefits — | |||||
** Base Plan ** | |||||
Premium | Total monthly premium: $0.00 | ||||
Health plan premium: $0.00 | |||||
Standard Part B premium: $135.50 | |||||
Part B premium reduction: No | |||||
Deductible | Health plan deductible: $150 annual deductible | ||||
Estimated yearly costs | Estimated total yearly costs for care: $6,390.00 | ||||
Out-of-pocket max | Out-of-pocket max: $10,000 In and Out-of-network $6,400 In-network | ||||
Doctor services | Primary doctor visit: In-network: $5 per visit Out-of-network: $30 per visit | ||||
Specialist visit: In-network: $20 per visit Out-of-network: $50 per visit | |||||
Tests, labs, & imaging | Diagnostic tests & procedures: In-network: $5-95 Out-of-network: 35% | ||||
Lab services: In-network: $5-20 Out-of-network: 35% | |||||
Diagnostic radiology services (like MRI): In-network: $5-200 Out-of-network: 35% | |||||
Outpatient x-rays: In-network: $5-25 Out-of-network: 35% | |||||
Emergency care: $90 per visit (always covered) | |||||
Urgent care: $5-20 per visit (always covered) | |||||
Hospital services | Inpatient hospital coverage: In-network: $225 per day for days 1 through 5 $0 per day for days 6 through 90 Out-of-network: 35% per stay | ||||
Outpatient hospital coverage: In-network: $20-150 per visit Out-of-network: 35% per visit | |||||
Skilled nursing facility | Skilled nursing facility: In-network: $0 per day for days 1 through 20 $178 per day for days 21 through 100 Out-of-network: 35% per stay | ||||
Preventive services | Preventive services: In-network: $0 copay Out-of-network: $0 copay | ||||
Ambulance | Ground ambulance: In-network: $275 Out-of-network: $275 | ||||
Therapy services | Occupational therapy visit: In-network: $20 Out-of-network: $50 | ||||
Physical therapy & speech & language therapy visit: In-network: $20 Out-of-network: $50 | |||||
Mental health services | Outpatient group therapy with a psychiatrist: In-network: $20 Out-of-network: $50 | ||||
Outpatient individual therapy with a psychiatrist: In-network: $20 Out-of-network: $50 | |||||
Outpatient group therapy visit: In-network: $20 Out-of-network: $50 | |||||
Outpatient individual therapy visit: In-network: $20 Out-of-network: $50 | |||||
Opioid treatment services | Opioid treatment services: Covered | ||||
Other services | Durable medical equipment (like wheelchairs & oxygen): In-network: 20% per item Out-of-network: 35% per item | ||||
Prosthetics (like braces, artificial limbs): In-network: 20% per item Out-of-network: 35% per item | |||||
Diabetes supplies: In-network: 0-20% per item Out-of-network: 0-20% per item | |||||
Hearing | Hearing exam: In-network: $20 Out-of-network: $50 | ||||
Fitting/evaluation: In-network: $20 Out-of-network: $50 | |||||
Hearing aids – Inner ear: Not covered | |||||
Hearing aids – Outer ear: Not covered | |||||
Hearing aids – Over the ear: Not covered | |||||
Preventive dental | Oral exam: In-network: $0 copay Out-of-network: $0 copay | ||||
Cleaning: In-network: $0 copay Out-of-network: $0 copay | |||||
Fluoride treatment: In-network: $0 copay Out-of-network: $0 copay | |||||
Dental x-rays: In-network: $0 copay Out-of-network: $0 copay | |||||
Comprehensive dental | Non-routine services: In-network: $0 copay Out-of-network: $0 copay | ||||
Diagnostic services: In-network: $0 copay Out-of-network: $0 copay | |||||
Restorative services: In-network: $0 copay Out-of-network: $0 copay | |||||
Endodontics: In-network: $0 copay Out-of-network: $0 copay | |||||
Periodontics: In-network: $0 copay Out-of-network: $0 copay | |||||
Extractions: In-network: $0 copay Out-of-network: $0 copay | |||||
Prosthodontics, other oral/maxillofacial surgery, other services: In-network: $0 copay Out-of-network: $0 copay | |||||
Vision | Routine eye exam: In-network: $0 copay Out-of-network: $0 copay | ||||
Contact lenses: In-network: $0 copay Out-of-network: $0 copay | |||||
Eyeglasses (frames & lenses): In-network: $0 copay Out-of-network: $0 copay | |||||
Eyeglass frames (only): In-network: $0 copay Out-of-network: $0 copay | |||||
Eyeglass lenses (only): In-network: $0 copay Out-of-network: $0 copay | |||||
Upgrades: In-network: $0 copay Out-of-network: $0 copay | |||||
More benefits | Fitness benefit: Limited coverage | ||||
Over the counter drug benefits: Limited coverage | |||||
In-home support services: Not covered | |||||
Home and bathroom safety devices: Not covered | |||||
Meals for short duration: Limited coverage | |||||
Annual physical exams: Limited coverage | |||||
Telehealth: Not covered | |||||
Part B drugs | Chemotherapy drugs: In-network: 20% Out-of-network: 35% | ||||
Other Part B drugs: In-network: 20% Out-of-network: 35% |