Choice Bronze HSA + Vision + Adult Dental

53932AL0110002
Expanded Bronze
EPO

Choice Bronze HSA + Vision + Adult Dental is an Expanded Bronze EPO plan by Celtic Insurance Company.

IMPORTANT: You are viewing the 2023 version of Choice Bronze HSA + Vision + Adult Dental 53932AL0110002. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Choice Bronze HSA + Vision + Adult Dental is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Choice Bronze HSA + Vision + Adult Dental 53932AL0110002.
Insurer: Celtic Insurance Company
Network Type: EPO
Metal Type: Expanded Bronze
HSA Eligible?: Yes
Plan ID: 53932AL0110002

Cost-Sharing Overview

Choice Bronze HSA + Vision + Adult Dental 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 Choice Bronze HSA + Vision + Adult Dental?

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

Choice Bronze HSA + Vision + Adult Dental offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Diabetes, Pregnancy
Notice Pregnancy: Yes
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 Choice Bronze HSA + Vision + Adult Dental 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

Choice Bronze HSA + Vision + Adult Dental 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
No Charge after deductible 100.00%
Specialist Visit
Covered
No Charge after deductible 100.00% One consult per specialist per day.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
No Charge after deductible 100.00% Billed as Primary Care Physician Office Visit.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
No Charge after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
No Charge after deductible 100.00%
Hospice Services
Covered
No Charge after deductible 100.00%
Routine Dental Services (Adult)
Covered
No Charge 100.00%1000 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Covered
No Charge 100.00%1 Visit(s) per Year
Urgent Care Centers or Facilities
Covered
No Charge after deductible 100.00%
Home Health Care Services
Covered
No Charge after deductible 100.00%
Emergency Room Services
Covered
No Charge after deductible No Charge after deductible
Emergency Transportation/Ambulance
Covered
No Charge after deductible No Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
No Charge after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
No Charge after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
No Charge after deductible 100.00%
Prenatal and Postnatal Care
Covered
No Charge after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
No Charge after deductible 100.00%20 Days per Year If mental Health services provided through Expanded Psychiatric Service (EPS) provider, 30 days of outpatient care covered, if not through EPS 20 days.
Mental/Behavioral Health Inpatient Services
Covered
No Charge after deductible 100.00%30 Days per Year 30 day limit when not coordinated by EPS provider.
Substance Abuse Disorder Outpatient Services
Covered
No Charge after deductible 100.00%20 Days per Year If mental Health services provided through Expanded Psychiatric Service (EPS) provider, 30 days of outpatient care covered, if not through EPS 20 days.
Substance Abuse Disorder Inpatient Services
Covered
No Charge after deductible 100.00%30 Days per Year
Generic Drugs
Covered
No Charge after deductible 100.00%
Preferred Brand Drugs
Covered
No Charge after deductible 100.00%
Non-Preferred Brand Drugs
Covered
No Charge after deductible 100.00%
Specialty Drugs
Covered
No Charge after deductible 100.00% A drug included in the Specialty Drug List may also be considered a generic, preferred brand name, or other brand name drug. If a drug falls into multiple categories, the drug will be considered a specialty drug, and not a generic drug or other type of drug, as long as it remains on the Specialty Drug List.
Outpatient Rehabilitation Services
Covered
No Charge after deductible 100.00% While outpatient rehab is not mentioned, occupational, physical and speech therapy with combined limit (30 visits per year).
Habilitation Services
Covered
No Charge after deductible 100.00%
Chiropractic Care
Covered
No Charge after deductible 100.00%
Durable Medical Equipment
Covered
No Charge after deductible 100.00% (1) artificial arms and other prosthetics, leg braces, and other orthopedic devices; (2) medical supplies such as oxygen, crutches, casts, catheters, colostomy bags and supplies, and splints.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
No Charge after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Visit(s) per Year
Eye Glasses for Children
Covered
No Charge 100.00%1 Visit(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
No Charge after deductible 100.00%30 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
No Charge after deductible 100.00%30 Visit(s) per Year
Well Baby Visits and Care
Covered
No Charge 100.00%9 Visit(s) per 2 Years Well baby visits are covered for the child’s first two years.
Laboratory Outpatient and Professional Services
Covered
No Charge after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
No Charge after deductible 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Covered
50.00% 100.00%1000 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Covered
50.00% 100.00%1000 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
No Charge after deductible 100.00%
Accidental Dental
Covered
No Charge after deductible 100.00%
Dialysis
Covered
No Charge after deductible 100.00%
Allergy Testing
Covered
No Charge after deductible 100.00%
Chemotherapy
Covered
No Charge after deductible 100.00% Covered under, Inpatient, Outpatient, and Physician Services.
Radiation
Covered
No Charge after deductible 100.00% Covered under, Inpatient, Outpatient, and Physician Services.
Diabetes Education
Covered
No Charge after deductible 100.00% Covered under disease management, which includes education.
Prosthetic Devices
Covered
No Charge after deductible 100.00% Artificial arms and other prosthetics, leg braces, and other orthopedic devices.
Infusion Therapy
Covered
No Charge after deductible 100.00% Covered under the Home Health benefit.
Treatment for Temporomandibular Joint Disorders
Not Covered
Nutritional Counseling
Not Covered
Reconstructive Surgery
Covered
No Charge after deductible 100.00% Requires member and doctor to prove surgery is reconstructive, not cosmetic by providing medical and photographic evidence prior to and after surgery.
Gender Affirming Care
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Outpatient Other Services
Covered
No Charge after deductible 100.00%
Substance Use Disorder Outpatient Other Services
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Emergency Room
Covered
No Charge after deductible No Charge after deductible
Substance Use Disorder Emergency Room
Covered
No Charge after deductible No Charge after deductible
Mental/Behavioral Health ER Physician Fee
Covered
No Charge after deductible No Charge after deductible
Substance Use Disorder ER Physician Fee
Covered
No Charge after deductible No Charge after deductible
Mental/Behavioral Health Emergency Transportation/Ambulance
Covered
No Charge after deductible No Charge after deductible
Substance Use Disorder Emergency Transportation/Ambulance
Covered
No Charge after deductible No Charge after deductible
Mental/Behavioral Health Urgent Care
Covered
No Charge after deductible 100.00%
Substance Use Disorder Urgent Care
Covered
No Charge after deductible 100.00%
Eyeglasses for Adults
Covered
No Charge 100.00%1 Visit(s) per Year Covered up to $130

Free Preventive Services

There is no copayment or coinsurance for any of the following Choice Bronze HSA + Vision + Adult Dental 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 Choice Bronze HSA + Vision + Adult Dental 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 Choice Bronze HSA + Vision + Adult Dental?

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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