Ascension Personalized Care Balanced Bronze
35755IN0080002
Expanded Bronze
EPO
Ascension Personalized Care Balanced Bronze is an Expanded Bronze EPO plan by US Health and Life.
IMPORTANT: You are viewing the 2024 version of Ascension Personalized Care Balanced Bronze 35755IN0080002. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.
Locations
Ascension Personalized Care Balanced Bronze is offered in the following counties.
Plan Overview
This is a plan overview for 2024 version of Ascension Personalized Care Balanced Bronze 35755IN0080002.
| Insurer: | US Health and Life |
| Network Type: | EPO |
| Metal Type: | Expanded Bronze |
| HSA Eligible?: | No |
| Plan ID: | 35755IN0080002 |
Cost-Sharing Overview
Ascension Personalized Care Balanced Bronze offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Ascension Personalized Care Balanced Bronze includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9450 per person | $18900 per group |
| Deductible: | $9450 per person | $18900 per group |
| Coinsurance: | 0.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Ascension Personalized Care Balanced Bronze will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $9,400.00 |
| Copayment: | $30.00 |
| Coinsurance: | $0.00 |
| Limit: | $60.00 |
| Deductible: | $4,300.00 |
| Copayment: | $300.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $2,795.00 |
| Copayment: | $5.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
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?
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 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 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 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 | $25.00 Not Applicable | Not Applicable 100.00% | |
| Specialist Visit Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Hospice Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Not Covered | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 82.0 Visit(s) per Year |
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Home Health Care Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 100.0 Visit(s) per Benefit Period Combined In and out of network. Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home. |
| Emergency Room Services Covered | Not Applicable No Charge after deductible | Not Applicable No Charge after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable No Charge after deductible | Not Applicable No Charge after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network. |
| Inpatient Physician and Surgical Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 90.0 Days per Benefit Period Limit is combined both In and Out of Network. |
| Prenatal and Postnatal Care Covered | $25.00 Not Applicable | Not Applicable 100.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Mental/Behavioral Health Outpatient Services Covered | $25.00 Not Applicable | Not Applicable 100.00% | Cost share driven by provider/setting. |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | $25.00 Not Applicable | Not Applicable 100.00% | Cost share driven by provider/setting. |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Generic Drugs Covered | $20.00 Not Applicable | Not Applicable 100.00% | |
| Preferred Brand Drugs Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Non-Preferred Brand Drugs Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Specialty Drugs Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Outpatient Rehabilitation Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 60.0 Visit(s) per Benefit Period Cost share is driven by provider/setting. Coverage for Speech Therapy is limited to 20 visits per benefit period, Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to 20 visits per benefit period. These limits are combined in and out of network. Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network. Cardiac Rehabilitation limited to 36 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network when rendered in the home, Home Care Services limits apply.Pulmonary Rehabilitation limited to 20 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network. When rendered in the home, Home Care Services limits apply. When rendered as part of physical therapy, the Physical Therapy limit will apply instead of the limit indicated. |
| Habilitation Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 60.0 Visit(s) per Benefit Period Cost share is driven by provider/setting. Benefits are separate for rehabilitative services and habilitative services and are provided at 20 visits each for PT, OT, ST for rehabilitative services and 20 visits each for habilitative services. Limits are combined both In and Out of Network. |
| Chiropractic Care Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 12.0 Visit(s) per Benefit Period Limit combined In and out of network. Cost share driven by provider/setting. |
| Durable Medical Equipment Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | One wig per benefit period combined both In and Out of Network. Network and Non-Network for wigs following cancer treatment. |
| Hearing Aids Not Covered | |||
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Preventive Care/Screening/Immunization Covered | No Charge No Charge | Not Applicable 100.00% | |
| Routine Foot Care Not Covered | |||
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | $25.00 Not Applicable | Not Applicable 100.00% | 1.0 Exam(s) per Year |
| Eye Glasses for Children Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 1.0 Item(s) per Year |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 20.0 Visit(s) per Benefit Period Combined In and out of network. Cost share driven by provider/setting. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 40.0 Visit(s) per Benefit Period Cost share is driven by provider/setting. Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period. Both apply to In-Network Providers and Non-Network Providers combined. Coverage also includes an additional 20 visits each for habilitative services. |
| Well Baby Visits and Care Covered | No Charge No Charge | Not Applicable 100.00% | |
| Laboratory Outpatient and Professional Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Cost share driven by provider/setting. |
| X-rays and Diagnostic Imaging Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Cost share driven by provider/setting. |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| 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 | Not Applicable No Charge after deductible | Not Applicable 100.00% | Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined). |
| Accidental Dental Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 3000.0 Dollars per Episode The limit will not apply to Outpatient facility charges, anesthesia billed by a Provider other than the Physician performing the service, or to services that we are required by law to cover. Cost share is driven by provider/setting. Limited to $3,000/accident; combined In and Out of network. Benefits for Accidental Dental are based on the setting in which Covered Services are recommended. |
| Dialysis Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Allergy Testing Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Cost share driven by provider/setting. |
| Chemotherapy Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Cost share driven by provider/setting. |
| Radiation Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Cost share driven by provider/setting. |
| Diabetes Education Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Prosthetic Devices Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Must be medically necessary. |
| Infusion Therapy Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Cost share driven by provider/setting. |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Nutritional Counseling Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Cost share driven by provider/setting. |
| Reconstructive Surgery Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed. Reconstructive services required due to prior therapeutic process are payable only if the original procedure would have been a covered service under this plan. |
| Gender Affirming Care Not Covered |
Free Preventive Services
There is no copayment or coinsurance for any of the following Ascension Personalized Care Balanced Bronze 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Ascension Personalized Care Balanced Bronze 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?
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