Ascension Personalized Care No Deductible Bronze

31663TN0010004
Expanded Bronze
EPO

Ascension Personalized Care No Deductible Bronze is an Expanded Bronze EPO plan by US Health and Life Insurance Company.

IMPORTANT: You are viewing the 2023 version of Ascension Personalized Care No Deductible Bronze 31663TN0010004. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Ascension Personalized Care No Deductible Bronze is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Ascension Personalized Care No Deductible Bronze 31663TN0010004.
Insurer: US Health and Life Insurance Company
Network Type: EPO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 31663TN0010004

Cost-Sharing Overview

Ascension Personalized Care No Deductible Bronze 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 No Deductible 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 No Deductible 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 No Deductible 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 No Deductible 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
$50.00 100.00%
Specialist Visit
Covered
$100.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$100.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
$1,000.00 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
$200.00 100.00%
Hospice Services
Covered
$2,000.00 100.00% Prior Authorization required for Inpatient Hospice.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
50.00% 100.00%
Home Health Care Services
Covered
50.00% 100.00%60 Visit(s) per Year
Emergency Room Services
Covered
$1,000.00 $1,000.00
Emergency Transportation/Ambulance
Covered
$1,000.00 $1,000.00
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
$2000.00 Copay per Day 100.00%
Inpatient Physician and Surgical Services
Covered
No Charge 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
$2000.00 Copay per Day 100.00%60 Days per Year Skilled Nursing and Rehabilitation Facility limited to 60 days/year combined.
Prenatal and Postnatal Care
Covered
$50.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
$2,000.00 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$50.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
$2000.00 Copay per Day 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$50.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
$2000.00 Copay per Day 100.00%
Generic Drugs
Covered
$30.00 100.00%
Preferred Brand Drugs
Covered
$150.00 100.00%
Non-Preferred Brand Drugs
Covered
$250.00 100.00%
Specialty Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Outpatient Rehabilitation Services
Covered
$100.00 100.00%20 Visit(s) per Year Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner’s office, outpatient facility or home health setting.
Habilitation Services
Covered
$100.00 100.00%20 Visit(s) per Year Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner’s office, outpatient facility or home health setting.
Chiropractic Care
Covered
50.00% 100.00%20 Visit(s) per Year Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for therapy, whether received in a Practitioner’s office, outpatient facility or home health setting.
Durable Medical Equipment
Covered
50.00% 100.00% Durable medical equipment over $500 requires prior authorization.
Hearing Aids
Covered
50.00% 100.00%1 Item(s) per 3 Years
Imaging (CT/PET Scans, MRIs)
Covered
$200.00 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge No Charge 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$50.00 100.00%1 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
50.00% 100.00%1 Item(s) per Benefit Period
Dental Check-Up for Children
Not Covered
1 Exam(s) per 6 Months
Rehabilitative Speech Therapy
Covered
$100.00 100.00%20 Visit(s) per Year Therapy limited to 20 visits per type per year. Physical, speech or occupational therapy provided in the home does not require Prior Authorization.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$100.00 100.00%20 Visit(s) per Year Therapy limited to 20 visits per type per year. Physical, speech or occupational therapy provided in the home does not require Prior Authorization.
Well Baby Visits and Care
Covered
No Charge No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
$50.00 100.00%
X-rays and Diagnostic Imaging
Covered
$100.00 100.00%
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
50.00% 100.00% Transplant services or supplies that have not received Prior Authorization will not be Covered.
Accidental Dental
Covered
50.00% 100.00%
Dialysis
Covered
50.00% 100.00%
Allergy Testing
Covered
$50.00 100.00%
Chemotherapy
Covered
50.00% 100.00%
Radiation
Covered
50.00% 100.00%
Diabetes Education
Covered
50.00% 100.00%
Prosthetic Devices
Covered
50.00% 100.00%
Infusion Therapy
Covered
50.00% 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
50.00% 100.00%
Nutritional Counseling
Covered
50.00% 100.00% For Diabetes Treatment only.
Reconstructive Surgery
Covered
50.00% 100.00% Covered Services: Surgery to correct significant defects from congenital causes, (except where specifically excluded), accidents or disfigurement from a disease state. Reconstructive breast Surgery as a result of a mastectomy or partial mastectomy (other than lumpectomy).
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following Ascension Personalized Care No Deductible 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.

Additional Resources

Below are additional resources for Ascension Personalized Care No Deductible 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 No Deductible 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

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