Find Health Plans

Ascension Personalized Care Balanced Bronze 1

32542KS0090001
Expanded Bronze
EPO

Ascension Personalized Care Balanced Bronze 1 is an Expanded Bronze EPO plan by US Health and Life Insurance Company.

IMPORTANT: You are viewing the 2023 version of Ascension Personalized Care Balanced Bronze 1 32542KS0090001. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Ascension Personalized Care Balanced Bronze 1 is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Ascension Personalized Care Balanced Bronze 1 32542KS0090001.
Insurer: US Health and Life Insurance Company
Network Type: EPO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 32542KS0090001

Cost-Sharing Overview

Ascension Personalized Care Balanced Bronze 1 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Ascension Personalized Care Balanced Bronze 1?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Ascension Personalized Care Balanced Bronze 1 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Ascension Personalized Care Balanced Bronze 1 covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description:
National Network: No

Additional Benefits and Cost-Sharing

Ascension Personalized Care Balanced Bronze 1 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$50.00 100.00%
Specialist Visit
Covered
$100.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$100.00 100.00% Professional Providers include Physician Assistants. Registered Nurses qualify as Eligible Providers.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
50.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
50.00% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
50.00% Coinsurance after deductible 100.00% Plan covers Diagnosis and treatment of cause of infertility. Benefits are available for covered services such as office visits, laboratory tests, and radiological studies to diagnose the cause of infertility. Benefits are also provided for the necessary treatment of the condition unless the treatment is identified as non-covered (see exclusions). For example, corrective surgical procedures, therapeutic injections, and drug therapy regimens (Pregnyl, Clomid, Clomiphene, Ovidrel, Gonal, Follistim and Cetrotide) are all covered services when medically necessary. Benefits are also available for tests, such as ultrasound, performed to monitor the effectiveness of the fertility drug therapy. Also for any necessary pregnancy testing performed as an integral part of the overall infertility treatment program. Benefits are excluded, however, for any procedures, tests, or other services that are exclusively provided to monitor the effectiveness of non-covered fertilization procedures.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
50.00% Coinsurance after deductible 100.00%
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
50.00% Coinsurance after deductible 100.00%
Home Health Care Services
Covered
50.00% Coinsurance after deductible 100.00% Includes educational visits with a limit of three per year on educational visits.
Emergency Room Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible Emergency transportation/ambulance within 500 mile radius.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
50.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Not Covered
Prenatal and Postnatal Care
Covered
$50.00 100.00% Also covers surrogate mother if there is a petition to adopt within 90 days of birth.
Delivery and All Inpatient Services for Maternity Care
Covered
50.00% Coinsurance after deductible 100.00% Also covers surrogate mother if there is a petition to adopt within 90 days of birth.
Mental/Behavioral Health Outpatient Services
Covered
$50.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$50.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$20.00 100.00%
Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Non-Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Specialty Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Outpatient Rehabilitation Services
Covered
50.00% Coinsurance after deductible 100.00%90 Days per Benefit Period These therapies include but are not limited to PT, OT, and ST. Further, ‘(Rehab) services are covered only if they are expected to result in significant improvement in the Insured’s condition. The Company, with appropriate medical consultation, will determine whether significant improvement has occurred’. ‘Speech Therapy’, limited to one service per day up to a maximum benefit of 90 daily services per Insured per Benefit Period. This limitation is not applicable to Mental Illness or Substance Use Disorders.
Habilitation Services
Covered
50.00% Coinsurance after deductible 100.00% Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Chiropractic Care
Covered
50.00% Coinsurance after deductible 100.00%
Durable Medical Equipment
Covered
50.00% Coinsurance after deductible 100.00% Benefits are limited to the amount normally available for a basic (standard) item which allows necessary function. Basic (standard) medical equipment is equipment that provides the essential function required for the treatment or amelioration of the medical condition at a Medically Necessary level. Charges for deluxe or electrically operated medical equipment are not covered, beyond the extent allowed for basic (standard) items. Deluxe describes medical equipment that has enhancements that allow for additional convenience or use beyond that provided by basic (standard) equipment.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
50.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge No Charge 100.00%
Routine Foot Care
Covered
No Charge No Charge 100.00% Covered when systemic conditions such as metabolic, neurologic, or peripheral vascular disease exists and results in medically significant circulatory deficits or decreased sensation to the foot.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge No Charge 100.00%
Eye Glasses for Children
Covered
No Charge No Charge 100.00%3 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
50.00% Coinsurance after deductible 100.00%90 Days per Benefit Period Limited to one service per day up to a maximum benefit of 90 daily services per Insured per Benefit Period. This limitation is not applicable to Mental Illness or Substance Use Disorders.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
50.00% Coinsurance after deductible 100.00%
Well Baby Visits and Care
Covered
No Charge No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
50.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
50.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Orthodontic services require prior authorization and are only covered for eligible children with cases of severe orthodontic abnormality caused by genetic deformity (such as cleft lip or cleft palate) or traumatic facial injury resulting in serious health impairment to the beneficiary at the present time.
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
50.00% Coinsurance after deductible 100.00% Benefits are provided for the following human organ transplants: Cornea; heart; heart-lung; kidney; pancreas; liver; lung (whole or lobar, single or double); small intestine; and multivisceral transplants.
Accidental Dental
Covered
50.00% Coinsurance after deductible 100.00% Oral Surgical Services and Services for Accidental Injuries to Sound Natural Teeth, limited to: (1) Surgical procedures of the jaw and gums. (2) Removal of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth. (3) Removal of exostoses (bony growths) of the jaw and hard palate. (4) Treatment of fractures and dislocations of the jaw and facial bones. (5) Surgical removal of impacted teeth. (6) Treatment of Sound Natural Teeth caused by an Accidental Injury. This includes replacement of Sound Natural Teeth lost due to the Accidental Injury. (7) Intra oral dental imaging services in connection with covered oral surgery if treatment begins within 30 days. (8) General anesthesia for covered oral surgery. (9) Cylindrical endosseous dental implants, mandibular staple implants, subperiosteal implants and the associated fixed and/or removable prosthetic appliance when provided because of an Accidental Injury. (10) Cylindrical endosseous dental implants, mandibular staple implants, subperiosteal implants andthe associated fixed and/or removable prosthetic appliances following surgical resection of either benign or malignant lesions (NOT including inflammatory lesions).
Dialysis
Covered
50.00% Coinsurance after deductible 100.00% Plan cover Hemodialysis.
Allergy Testing
Covered
50.00% Coinsurance after deductible 100.00% Allergy testing and treatment.
Chemotherapy
Covered
50.00% Coinsurance after deductible 100.00%
Radiation
Covered
50.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
50.00% Coinsurance after deductible 100.00% Outpatient self-management training and education, including medical nutrition therapy, for insulin dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin using diabetes when provided by a certified, registered or licensed health care professional with expertise in diabetes and the diabetic (1) is treated at a program approved by the American Diabetes Association; (2) is treated by a person certified by the national certification board of diabetes educators; or (3) is, as to nutritional education, treated by a licensed dietitian pursuant to a treatment plan authorized by such healthcare professional.
Prosthetic Devices
Covered
50.00% Coinsurance after deductible 100.00% Benefits are limited to the amount normally available for a basic (standard) appliance which allows necessary function. Basic (standard) medical devices or appliances are those that provide the essential function required for the treatment or amelioration of the medical condition at a Medically Necessary level.
Infusion Therapy
Covered
50.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
50.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Not Covered
Reconstructive Surgery
Covered
50.00% Coinsurance after deductible 100.00% Cosmetic and reconstructive are generally excluded, but excepted from this exclusion are: a. Cosmetic or reconstructive repair of an Accidental Injury.; b. Reconstructive breast surgery in connection with a Medically Necessary mastectomy that resulted from a medical illness or injury. This includes reconstructive surgery on a breast on which a mastectomy was not performed in order to produce a symmetrical appearance.; c. Repair of congenital abnormalities and hereditary complications or conditions, limited to: (1) Cleft lip or palate. (2) Birthmarks on head or neck. (3) Webbed fingers or toes. (4) Supernumerary fingers or toes.; d. Reconstructive services performed on structures of the body to improve/restore impairments of bodily function resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes. For purposes of this provision, the term ‘cosmetic’ means procedures and related services performed to reshape structures of the body in order to alter the individual’s appearance.
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following Ascension Personalized Care Balanced Bronze 1 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Ascension Personalized Care Balanced Bronze 1 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Ascension Personalized Care Balanced Bronze 1?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Table of Contents