Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth)

27248TX0010016
Expanded Bronze
HMO

Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth) is an Expanded Bronze HMO plan by Community Health Choice.

IMPORTANT: You are viewing the 2023 version of Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth) 27248TX0010016. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth) 27248TX0010016.
Insurer: Community Health Choice
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 27248TX0010016

Cost-Sharing Overview

Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth) 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 Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth)?

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

Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth) offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Diabetes, 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 Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth) 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: For emergency only
National Network: No

Additional Benefits and Cost-Sharing

Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth) 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
$35.00 100.00%
Specialist Visit
Covered
$90.00 Copay after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$35.00 100.00% Cost sharing and limitations depend on type and site of service.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
50.00% Coinsurance after deductible 100.00% Cost sharing and limitations depend on type and site of service. Preauthorization is required for outpatient surgeries.
Outpatient Surgery Physician/Surgical Services
Covered
50.00% Coinsurance after deductible 100.00% Outpatient services and Habilitation Services are subject to different cost-sharing depending on whether the service is an office visit or other outpatient service. Office visits are subject to copays, while facility-based services are subject to coinsurance. Preauthorization is required for outpatient surgeries.
Hospice Services
Covered
$90.00 Copay after deductible 100.00% Cost sharing and limitations depend on the type and site of service.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
$90.00 Copay after deductible 100.00% Inpatient private duty nursing.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$90.00 100.00%
Home Health Care Services
Covered
$90.00 Copay after deductible 100.00%60 Visit(s) per Year Prior Authorization is required.
Emergency Room Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
$90.00 Copay after deductible $90.00 Copay after deductible Travel or ambulance services for convenience. Prior authorization required for out of network ambulance services, out of area transfers, non-emergency ground transportation, air transportation, and facility to facility transfers. Prior authorization is not necessary when the service is medically necessary and any other form of transportation would put the Member?s health or safety at risk. As of January 1, 2022, the No Surprises Act prohibits surprise billing for Consumers with Out-of-Network emergency services, including air ambulance (but not ground ambulance) services.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
50.00% Coinsurance after deductible 100.00% Prior Authorization is required.
Inpatient Physician and Surgical Services
Covered
No Charge after deductible 100.00% Prior Authorization is required for inpatient surgical services.
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
50.00% Coinsurance after deductible 100.00%25 Days per Year Cost sharing and limitation depend on type and site of service. Prior authorization is required.
Prenatal and Postnatal Care
Covered
$90.00 Copay after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
50.00% Coinsurance after deductible 100.00% Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section. Prior authorization required for maternity and newborn stays that exceed 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.
Mental/Behavioral Health Outpatient Services
Covered
$35.00 100.00% Certain services require preauthorization. Cost sharing depends on type and site of service. This benefit (Mental/Behavioral Health Outpatient Services, Substance Abuse Disorder Outpatient Services, and Habilitation Services) is subject to different cost-sharing depending on whether the service is an office visit or other outpatient service. Office visits are subject to copays, while facility-based services are subject to coinsurance.
Mental/Behavioral Health Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00% Preauthorization is required.
Substance Abuse Disorder Outpatient Services
Covered
$35.00 100.00% Certain services require preauthorization. Cost sharing depends on type and site of service. This benefit (Mental/Behavioral Health Outpatient Services, Substance Abuse Disorder Outpatient Services, and Habilitation Services) is subject to different cost-sharing depending on whether the service is an office visit or other outpatient service. Office visits are subject to copays, while facility-based services are subject to coinsurance.
Substance Abuse Disorder Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00% Preauthorization is required.
Generic Drugs
Covered
$30.00 100.00% Subject to formulary requirements and preauthorization may be required (when generic is not the preferred agent).
Preferred Brand Drugs
Covered
$60.00 Copay after deductible 100.00% Subject to formulary requirements and preauthorization may be required.
Non-Preferred Brand Drugs
Covered
$130.00 Copay after deductible 100.00% Subject to formulary requirements and preauthorization may be required.
Specialty Drugs
Covered
50.00% Coinsurance after deductible 100.00% Subject to formulary requirements and preauthorization may be required.
Outpatient Rehabilitation Services
Covered
$90.00 Copay after deductible 100.00% Limited to Medically Necessary outpatient Rehabilitative Therapy visits to or by a Participating Provider other than a Primary Care Physician. Prior authorization is required.
Habilitation Services
Covered
$90.00 Copay after deductible 100.00% Cost sharing depends on type and site of service. Limited to medical necessity. Prior authorization is required.
Chiropractic Care
Covered
$90.00 Copay after deductible 100.00%35 Visit(s) per Year Limited to combined 35 visits per year.
Durable Medical Equipment
Covered
30.00% Coinsurance after deductible 100.00% Certain services require preauthorization (DME over $500).
Hearing Aids
Covered
30.00% Coinsurance after deductible 100.00%1 Item(s) per 3 Years To restore or correction of impaired speech or hearing loss. Each ear, every three years. Prior authorization is required.
Imaging (CT/PET Scans, MRIs)
Covered
50.00% Coinsurance after deductible 100.00% Preauthorization is required.
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%
Routine Foot Care
Covered
$90.00 Copay after deductible 100.00% Coverage for foot care is limited to members with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency is covered. Any services or supplies in connection with routine foot care, including the removal of warts, corns, or calluses, or the cutting and trimming of toenails in the absence of diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency are excluded. Cost sharing and limitations depend on site of service.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$90.00 Copay after deductible 100.00%1 Visit(s) per Year Covered services for children 18 and under.
Eye Glasses for Children
Covered
$90.00 Copay after deductible 100.00%1 Item(s) per Year For select frames, standard lenses, and contact lenses only.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$90.00 Copay after deductible 100.00% Prior Authorization is required. Limited to medical necessity.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$90.00 Copay after deductible 100.00% Prior Authorization is required. Limited to medical necessity.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
$35.00 Copay after deductible 100.00% Some services require preauthorization.
X-rays and Diagnostic Imaging
Covered
$35.00 Copay after deductible 100.00% Prior Authorization is required.
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% Coinsurance after deductible 100.00% Subject to the conditions described below, benefits for covered services and supplies provided to a Participant by a Hospital, Physician, or Other Provider related to an organ or tissue transplant will be determined as follows, but only if all the following conditions are met: (1) The transplant procedure is not Experimental/Investigational in nature; and (2) Donated human organs or tissue or an FDA-approved artificial device are used; and (3) The recipient is a Participant under the Plan; and (4) The transplant procedure is preauthorized as required under the Plan; and (5) The Participant meets all of the criteria established by CHC in pertinent written medical policies; and (6) The Participant meets all of the protocols established by the Hospital in which the transplant is performed. Donor expenses for a Participant in connection with an organ or tissue transplant is not a covered benefit if the recipient is not covered under this Plan. No benefits are available for any organ or tissue transplant procedure (or services performed in preparation for, or in conjunction with, such procedure) which CHC considers to be Experimental/Investigational. Preauthorization is required. Cost sharing and limitation depend on type and site of service.
Accidental Dental
Covered
$90.00 Copay after deductible 100.00% Cost sharing and limitation depend on type and site of service. Limited to treatment for a Dental Injury to a Sound Natural Tooth.
Dialysis
Covered
$90.00 Copay after deductible 100.00% Cost sharing depends on type and site of service.
Allergy Testing
Covered
$35.00 Copay after deductible 100.00% Cost sharing depends on type and site of service.
Chemotherapy
Covered
$90.00 Copay after deductible 100.00% Cost sharing and limitation depend on type and site of service. Injectable chemotherapeutic agents require preauthorization.
Radiation
Covered
$90.00 Copay after deductible 100.00% Cost sharing and limitation depend on type and site of service. Proton beam radiation requires preauthorization.
Diabetes Education
Covered
$35.00 Copay after deductible 100.00% Cost sharing depends on type and site of service.
Prosthetic Devices
Covered
30.00% Coinsurance after deductible 100.00% Preauthorization is required.
Infusion Therapy
Covered
$90.00 Copay after deductible 100.00% Cost sharing and limitation depend on type and site of service. Preauthorization is required.
Treatment for Temporomandibular Joint Disorders
Covered
$90.00 Copay after deductible 100.00% Prior authorization required for temporomandibular joint surgery.
Nutritional Counseling
Covered
$35.00 Copay after deductible 100.00% Preauthorization is required. Cost sharing depends on type and site of service.
Reconstructive Surgery
Covered
50.00% Coinsurance after deductible 100.00% Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. Preauthorization is required. Cost sharing depends on type and site of service.
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth) 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 Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth) 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 Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth)?

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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