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Market HMO 3850

99969OH0080493
Silver
HMO

Market HMO 3850 is a Silver HMO plan by MedMutual.

IMPORTANT: You are viewing the 2024 version of Market HMO 3850 99969OH0080493. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Market HMO 3850 is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Market HMO 3850 99969OH0080493.
Insurer: MedMutual
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 99969OH0080493

Cost-Sharing Overview

Market HMO 3850 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 Market HMO 3850?

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

Market HMO 3850 offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Diabetes
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 Market HMO 3850 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 Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Covered as Non-Network
National Network: No

Additional Benefits and Cost-Sharing

Market HMO 3850 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
$30.00 30.00% Coinsurance after deductibleNot Applicable 100.00% The first 3 combined visits to Primary Care Physician, Specialist, Other Practitioner, Urgent Care, Outpatient Substance Abuse, or Outpatient Mental Health are subject to Copay. After 3 visits, subject to Deductible and Coinsurance. On Demand Telemedicine: 0% after $0 Copay, unlimited.
Specialist Visit
Covered
$90.00 30.00% Coinsurance after deductibleNot Applicable 100.00% The first 3 combined visits to Primary Care Physician, Specialist, Other Practitioner, Urgent Care, Outpatient Substance Abuse, or Outpatient Mental Health are subject to Copay. After 3 visits, subject to Deductible and Coinsurance.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 30.00% Coinsurance after deductibleNot Applicable 100.00% The first 3 combined visits to Primary Care Physician, Specialist, Other Practitioner, Urgent Care, Outpatient Substance Abuse, or Outpatient Mental Health are subject to Copay. After 3 visits, subject to Deductible and Coinsurance.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% Only diagnostic and exploratory procedures required to diagnose infertility and certain surgical procedures to correct the medically diagnosed disease or condition of the reproductive organs are covered.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%90.0 Days per Benefit Period
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$90.00 30.00% Coinsurance after deductibleNot Applicable 100.00% The first 3 combined visits to Primary Care Physician, Specialist, Other Practitioner, Urgent Care, Outpatient Substance Abuse, or Outpatient Mental Health are subject to Copay. After 3 visits, subject to Deductible and Coinsurance. On Demand Telemedicine: 0% after $0 Copay, unlimited.
Home Health Care Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%100.0 Visit(s) per Benefit Period
Emergency Room Services
Covered
$350.00 30.00%$350.00 30.00%
Emergency Transportation/Ambulance
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 30.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services.
Inpatient Physician and Surgical Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% One (1) Inpatient visit per day per Physican or other Professional Provider
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%90.0 Days per Benefit Period
Prenatal and Postnatal Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$0.00 Not ApplicableNot Applicable 100.00% Tier 1 Generics include only the drugs listed in Tier 1A Generic Standard Plus Preventive on the ACA Advantage Formulary. Tier 2 Generics are all other generic medications listed on the ACA Advantage Formulary under Tier 1B. Generic drugs are copies of brand-name drugs that contain the same active ingredients but are usually less expensive. They also must meet the same strict U.S. Food and Drug Administration (FDA) standards for quality, strength and purity. If you fill a Generic drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual.
Preferred Brand Drugs
Covered
$60.00 Not ApplicableNot Applicable 100.00% Preferred Brand-name drugs, your second cost-share tier, are included in Medical Mutual’s formulary and are typically less expensive than similar Non-preferred Brand-name drugs. They are safe, effective alternatives to other brand-name drugs that may cost more. If you fill a Preferred Brand-name drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual.
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00%Not Applicable 100.00% Non-preferred Brand-name drugs, your third cost-share tier, are included in Medical Mutual?s formulary but are typically more expensive than similar Preferred Brand-name drugs. If you fill a Non-preferred Brand-name drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual.
Specialty Drugs
Covered
Not Applicable 50.00%Not Applicable 100.00% Specialty drugs must be obtained through a contracted specialty pharmacy, and are limited to a 30-day supply.
Outpatient Rehabilitation Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% 20 visits for Speech Therapy, 20 visits for Pulmonary Rehabilitation and 36 visits for Cardiac Rehabilitation.? Benefit also includes Physical Medicine and Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services.
Habilitation Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% This includes coverage for those with a medical diagnosis of Autism Spectrum disorder. These limits apply: 20 visits per year for Speech Therapy; 20 visits per year for Occupational Therapy; and 20 visits per year for Physical Therapy.
Chiropractic Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%12.0 Visit(s) per Benefit Period
Durable Medical Equipment
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% Cochlear implants are covered. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable No ChargeNot Applicable 100.00% Pap test – one per benefit period. Mammogram – one per benefit period.
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
Not Applicable No ChargeNot Applicable 100.00% Preventive services only.? See plan certificate for more information.
Eye Glasses for Children
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per Year
Dental Check-Up for Children
Covered
Not Applicable No ChargeNot Applicable 100.00%2.0 Exam(s) per Benefit Period
Rehabilitative Speech Therapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Benefit Period
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%40.0 Visit(s) per Benefit Period 20 visits for Rehabilitative Occupational Therapy and 20 visits for Rehabilitative Physical Therapy
Well Baby Visits and Care
Covered
Not Applicable No ChargeNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Covered
Not Applicable No ChargeNot Applicable 100.00%
Orthodontia – Child
Covered
Not Applicable No ChargeNot Applicable 100.00% Medically necessary only
Major Dental Care – Child
Covered
Not Applicable No ChargeNot Applicable 100.00%
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
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% Per Transplant: $30,000 maximum for unrelated donor search. $10,000 maximum for transportation, meals & lodging.
Accidental Dental
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable No ChargeNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Reconstructive Surgery
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Gender Affirming Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Market HMO 3850 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 Market HMO 3850 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 Market HMO 3850?

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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