MercyCare HMO Bronze Standard Expanded

54322IL0090012
Expanded Bronze
HMO

MercyCare HMO Bronze Standard Expanded is an Expanded Bronze HMO plan by MercyCare Health Plans.

IMPORTANT: You are viewing the 2023 version of MercyCare HMO Bronze Standard Expanded 54322IL0090012. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

MercyCare HMO Bronze Standard Expanded is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of MercyCare HMO Bronze Standard Expanded 54322IL0090012.
Insurer: MercyCare Health Plans
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 54322IL0090012

Cost-Sharing Overview

MercyCare HMO Bronze Standard Expanded 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 MercyCare HMO Bronze Standard Expanded?

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

MercyCare HMO Bronze Standard Expanded offers the following features and referral requirements.

Wellness Program: No
Disease Program: Heart Disease, Diabetes, High Blood Pressure & High Cholesterol
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: All
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what MercyCare HMO Bronze Standard Expanded covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description: Limited to emergency services only
Out of Service Area Coverage: No
Out of Service Area Coverage Description: Limited to emergency services only
National Network: No

Additional Benefits and Cost-Sharing

MercyCare HMO Bronze Standard Expanded 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
$50.00 100.00%
Specialist Visit
Covered
$100.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$50.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
50.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
50.00% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
50.00% Coinsurance after deductible 100.00% Limitations vary based on procedures.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
50.00% Coinsurance after deductible 100.00% Outpatient coverage only
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$75.00 $75.00
Home Health Care Services
Covered
50.00% Coinsurance after deductible 100.00%
Emergency Room Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
50.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
50.00% Coinsurance after deductible 100.00%
Cosmetic Surgery
Covered
50.00% Coinsurance after deductible 100.00% Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered.
Skilled Nursing Facility
Covered
50.00% Coinsurance after deductible 100.00%
Prenatal and Postnatal Care
Covered
50.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
50.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$50.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$50.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$25.00 100.00%
Preferred Brand Drugs
Covered
$50.00 Copay after deductible 100.00%
Non-Preferred Brand Drugs
Covered
$100.00 Copay after deductible 100.00%
Specialty Drugs
Covered
$500.00 Copay after deductible 100.00%
Outpatient Rehabilitation Services
Covered
$50.00 100.00% Maintenance therapies not covered.
Habilitation Services
Covered
50.00% Coinsurance after deductible 100.00%60 Visit(s) per Benefit Period Treatment must be medically necessary and therapeutic and not investigational.
Chiropractic Care
Covered
$50.00 100.00%25 Visit(s) per Benefit Period
Durable Medical Equipment
Covered
50.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
50.00% Coinsurance after deductible 100.00%2 Item(s) per 2 Years Benefits are for bone anchored hearing aids. $2,500 dollar limit per year for adults age 18 and over.
Imaging (CT/PET Scans, MRIs)
Covered
50.00% Coinsurance after deductible 100.00% Benefit provided for outpatient services and when these services are related to surgery or medical.
Preventive Care/Screening/Immunization
Covered
0.00% 100.00%
Routine Foot Care
Covered
50.00% Coinsurance after deductible 100.00% Only covered for persons diagnosed with diabetes.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$100.00 100.00%1 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
50.00% Coinsurance after deductible 100.00%1 Item(s) per Benefit Period
Dental Check-Up for Children
Not Covered
Select State offered plan
Rehabilitative Speech Therapy
Covered
$50.00 100.00%60 Visit(s) per Benefit Period When rendered for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome) attention disorder, conceptual handicap or mental retardation, except as may be provided under this Certificate for Autism Spectrum Disorder(s).
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$50.00 100.00%60 Visit(s) per Benefit Period Maintenance Speech Therapy is not covered.
Well Baby Visits and Care
Covered
No Charge No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
50.00% Coinsurance after deductible 100.00% Benefit provided for outpatient services and when these services are related to surgery or medical care.
X-rays and Diagnostic Imaging
Covered
50.00% Coinsurance after deductible 100.00% Benefit provided for outpatient services and when these services are related to surgery or medical care.
Basic Dental Care – Child
Not Covered
Select State offered plan
Orthodontia – Child
Not Covered
Select State offered plan
Major Dental Care – Child
Not Covered
Select State offered plan
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Covered
50.00% Coinsurance after deductible 100.00%
Transplant
Covered
50.00% Coinsurance after deductible 100.00%
Accidental Dental
Covered
50.00% Coinsurance after deductible 100.00%
Dialysis
Covered
50.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
50.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
50.00% Coinsurance after deductible 100.00%
Radiation
Covered
50.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
50.00% Coinsurance after deductible 100.00% Services must be rendered by a physician, or duly certified, or licensed health care professional with expertise in diabetes management.
Prosthetic Devices
Covered
50.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
50.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
50.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
$100.00 100.00%
Reconstructive Surgery
Covered
50.00% Coinsurance after deductible 100.00% Only includes benefits for mastectomy-related services.
Gender Affirming Care
Covered
50.00% Coinsurance after deductible 100.00%
Amino Acid-Based Elemental Formulas
Covered
50.00% Coinsurance after deductible 100.00%
Osteoporosis
Covered
No Charge No Charge 100.00%
Autism Spectrum Disorders
Covered
$50.00 100.00%
Breast Implant Removal
Covered
50.00% Coinsurance after deductible 100.00% Does not apply for implants implanted solely for cosmetic reasons
Multiple Sclerosis Preventative Physical Therapy
Covered
$50.00 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following MercyCare HMO Bronze Standard Expanded 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 MercyCare HMO Bronze Standard Expanded 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 MercyCare HMO Bronze Standard Expanded?

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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