Essentia Choice Care with Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)

57845WI0060011
Expanded Bronze
EPO

Essentia Choice Care with Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) is an Expanded Bronze EPO plan by Medica.

IMPORTANT: You are viewing the 2023 version of Essentia Choice Care with Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) 57845WI0060011. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Essentia Choice Care with Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Essentia Choice Care with Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) 57845WI0060011.
Insurer: Medica
Network Type: EPO
Metal Type: Expanded Bronze
HSA Eligible?: Yes
Plan ID: 57845WI0060011

Cost-Sharing Overview

Essentia Choice Care with Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) 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 Essentia Choice Care with Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)?

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

Essentia Choice Care with Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, 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 Essentia Choice Care with Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency Services
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency Services
National Network: No

Additional Benefits and Cost-Sharing

Essentia Choice Care with Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) 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
5.00% Coinsurance after deductible 100.00%
Specialist Visit
Covered
5.00% Coinsurance after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
5.00% Coinsurance after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
5.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
5.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
5.00% Coinsurance after deductible 100.00%
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
5.00% Coinsurance after deductible 5.00% Coinsurance after deductible
Home Health Care Services
Covered
5.00% Coinsurance after deductible 100.00%60 Visit(s) per Year
Emergency Room Services
Covered
5.00% Coinsurance after deductible 5.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
5.00% Coinsurance after deductible 5.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
5.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
5.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
5.00% Coinsurance after deductible 100.00%30 Days per Stay
Prenatal and Postnatal Care
Covered
5.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
5.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
5.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Inpatient Services
Covered
5.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
5.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Inpatient Services
Covered
5.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
5.00% Coinsurance after deductible 100.00%
Preferred Brand Drugs
Covered
5.00% Coinsurance after deductible 100.00% Prescription insulin will not exceed $25 per prescription unit
Non-Preferred Brand Drugs
Covered
5.00% Coinsurance after deductible 100.00%
Specialty Drugs
Covered
5.00% Coinsurance after deductible 100.00%
Outpatient Rehabilitation Services
Covered
5.00% Coinsurance after deductible 100.00%
Habilitation Services
Covered
5.00% Coinsurance after deductible 100.00%
Chiropractic Care
Covered
5.00% Coinsurance after deductible 100.00%
Durable Medical Equipment
Covered
5.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
5.00% Coinsurance after deductible 100.00%
Imaging (CT/PET Scans, MRIs)
Covered
5.00% Coinsurance 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
5.00% Coinsurance after deductible 100.00%
Eye Glasses for Children
Covered
5.00% Coinsurance after deductible 100.00%
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
5.00% Coinsurance after deductible 100.00%20 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
5.00% Coinsurance after deductible 100.00%20 Visit(s) per Year Limit of 20 visits for PT, 20 visits for OT
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
5.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
5.00% Coinsurance after deductible 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
5.00% Coinsurance after deductible 100.00%
Accidental Dental
Covered
5.00% Coinsurance after deductible 100.00%
Dialysis
Covered
5.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
5.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
5.00% Coinsurance after deductible 100.00% Intravenous chemotherapy is covered.
Radiation
Covered
5.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
5.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
5.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
5.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
5.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Not Covered
Reconstructive Surgery
Covered
5.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Covered
5.00% Coinsurance after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Essentia Choice Care with Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) 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 Essentia Choice Care with Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) 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 Essentia Choice Care with Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)?

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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