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.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth) includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9,100.00 | $9100 per person | $18200 per group |
| Deductible: | $8,100.00 | $8100 per person | $16200 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 Community Select Bronze 016 (Limited Network, No deductible for PCP & Generics, Free 24/7 Telehealth) will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | $8,100.00 (in-and-out of network) | $8100 per person (in-and-out of network) | $16200 per group (in-and-out of network) |
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: | $8,100.00 |
| Copayment: | $0.00 |
| Coinsurance: | $1,000.00 |
| Limit: | $60.00 |
| Deductible: | $4,300.00 |
| Copayment: | $400.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $2,800.00 |
| Copayment: | $10.00 |
| 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 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.
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 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