UHC Bronze Value HSA

40702AZ0060013
Expanded Bronze
HMO

UHC Bronze Value HSA is an Expanded Bronze HMO plan by UnitedHealthcare.

IMPORTANT: You are viewing the 2024 version of UHC Bronze Value HSA 40702AZ0060013. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

UHC Bronze Value HSA is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of UHC Bronze Value HSA 40702AZ0060013.
Insurer: UnitedHealthcare
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: Yes
Plan ID: 40702AZ0060013

Cost-Sharing Overview

UHC Bronze Value HSA 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 UHC Bronze Value HSA?

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

UHC Bronze Value HSA offers the following features and referral requirements.

Wellness Program: No
Disease Program:
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: All, except OBGYN and as state mandated
Plan Exclusions: 0
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what UHC Bronze Value HSA 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: Yes
Out of Service Area Coverage Description: Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area.
National Network: No

Additional Benefits and Cost-Sharing

UHC Bronze Value HSA 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
Not Applicable No Charge after deductibleNot Applicable 100.00% Cost sharing for Virtual Primary Care matches in-person office visit. See SBC for additional cost share details.
Specialist Visit
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% Services of a person who is a member of your family or your dependent’s family or who normally resides in your house or your dependent’s house; Services and supplies for curative or life prolonging procedures; Services and supplies for which any other benefits are payable under the Plan; Services and supplies that are primarily to aid you or your dependent in daily living; Services and supplies for respite (custodial) care; and Nutritional supplements, non-prescription drugs or substances, medical supplies, vitamins or minerals. The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% Private Duty Nursing services provided in the home. Private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Private duty nursing is available only in an inpatient setting when skilled nursing is not available from the facility. Custodial Nursing is not covered by the Plan.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$75 Copay after deductible Not ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%42.0 Visit(s) per Year Home health services do not include services of a person who is a member of your family or your dependent?s family or who normally resides in your house or your dependent?s house. 1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.; 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.; 3. The patient must be homebound unless services are determined to be medically necessary.; 4. The home health agency delivering care must be certified within the state the care is received.; 5. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of services.
Emergency Room Services
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 30% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 30% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% The following bariatric procedures are excluded: 1. Open vertical banded gastroplasty; 2. Laparoscopic vertical banded gastroplasty; 3. Open sleeve gastrectomy; 4. Open adjustable gastric banding. 1. The patient must have a body-mass index (BMI) of at least 35. 2. Have at least one co-morbidity related to obesity. 3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient’s medical record: Active participation within the last two years in one physician?supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of all of the following components: a. Weight b. Current dietary program c. Physical activity (e.g., exercise program) 4. In addition, the procedure must be performed at an approved Center of Excellence facility that is credentialed by your Health Network to perform bariatric surgery. 5. The member must be 18 years or older, or have reached full expected skeletal growth.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%90.0 Days per Year
Prenatal and Postnatal Care
Covered
Not Applicable No ChargeNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% Childbirth/delivery professional services follow inpatient physician/surgeon fees.
Mental/Behavioral Health Outpatient Services
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management.
Substance Abuse Disorder Outpatient Services
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management.
Generic Drugs
Covered
$5 Copay after deductible Not ApplicableNot Applicable 100.00%30.0 Days per Month 90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan’s Summary of Benefits or Prescription Drug List for more information.
Preferred Brand Drugs
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%30.0 Days per Month 90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan’s Summary of Benefits or Prescription Drug List for more information.
Non-Preferred Brand Drugs
Covered
Not Applicable 45.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Days per Month 90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan’s Summary of Benefits or Prescription Drug List for more information.
Specialty Drugs
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%30.0 Days per Month Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply.
Outpatient Rehabilitation Services
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Year The following limitations apply to short-term rehabilitative therapy except as required for the treatment for Autism Spectrum Disorder: 1. Occupational therapy is provided only for purposes of training Members to perform the activities of daily living. 2. Speech therapy is not covered when: a. Used to improve speech skills that have not fully developed; b. Considered custodial or educational; c. Intended to maintain speech communication; or d. Not restorative in nature. 3. Phase 3 cardiac rehabilitation is not covered. If multiple services are provided on the same day by different Providers, a separate co-payment will apply to each Provider. Short-term rehabilitative therapy includes services in an outpatient facility or physician?s office that is part of a rehabilitation program, including physical, speech, occupational, cardiac rehabilitation and pulmonary rehabilitation therapy. Visit limit is for all therapy types combined.
Habilitation Services
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Year Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Chiropractic Care
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Year 1. Services of a chiropractor or osteopath which are not within his scope of practice, as defined by state law; 2. Charges for care not provided in an office setting; 3. Maintenance or preventive treatment consisting of routine, long term or Non-Medically Appropriate care provided to prevent reoccurrences or to maintain the patient?s current status; and 4. Vitamin therapy. HMOs may limit chiropractic visits to 20; PPOs must cover medically necessary chiropractic visits.
Durable Medical Equipment
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% 1. Hygienic or self-help items or equipment; 2. Items or equipment primarily used for comfort or convenience such as bathtub chairs, safety grab bars, stair gliders or elevators, over-the-bed tables, saunas or exercise equipment; 3. Environmental control equipment, such as air purifiers, humidifiers and electrostatic machines; 4. Institutional equipment, such as air fluidized beds and diathermy machines; 5. Elastic stockings and wigs (except were indicated for coverage); 6. Equipment used for the purpose of participation in sports or other recreational activities including, but not limited to, braces and splints; 7. Items, such as auto tilt chairs, paraffin bath units and whirlpool baths, which are not generally accepted by the medical profession as being therapeutically effective; 8. Items which under normal use would constitute a fixture to real property, such as lifts, ramps, railings, and grab bars; and 9. Hearing aid batteries (except those for cochlear implants) and chargers.
Hearing Aids
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per Year
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable No ChargeNot Applicable 100.00%1.0 Exam(s) per Year Well Woman and Well Man examinations are limited to 1 visit per year.
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%1.0 Visit(s) per Year
Eye Glasses for Children
Covered
Not Applicable 30% 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%1.0 Visit(s) per 6 Months
Rehabilitative Speech Therapy
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Year Visit limit is for all therapy types combined (PT, OT, ST).
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Year Visit limit is for all therapy types combined (PT, OT, ST).
Well Baby Visits and Care
Covered
Not Applicable No ChargeNot Applicable 100.00% Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics.
Laboratory Outpatient and Professional Services
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% Benefit limitations may apply to individual services.
Orthodontia – Child
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00% Coverage is for medically necessary orthodontia only.
Major Dental Care – Child
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% Benefit limitations may apply to individual services.
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% Coinsurance after deductibleNot Applicable 100.00% These benefits are available when the Member is the recipient of an organ transplant. No coverage if Member is an organ donor for a recipient other than a Member enrolled under this plan. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary. Travel & lodging expenses are limited to $10,000 per transplant. Travel and lodging are not covered if the Member is a donor. Organ transplant services include the recipient?s medical, surgical and hospital services; inpatient immunosuppressive medications; and costs for organ procurement. Transplant services are covered only if they are required to perform human to human organ or tissue transplants, such as: 1. Allogeneic bone marrow/stem cell; 2. Autologous bone marrow/stem cell; 3. Cornea; 4. Heart; 5. Heart/lung; 6. Kidney; 7. Kidney/pancreas; 8. Liver; 9. Lung; 10. Pancreas; 11. Small bowel/liver; or 12. Kidney/liver. Organ transplant coverage will apply only to non-experimental transplants for the specific diagnosis. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary.
Accidental Dental
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% Replacement of external prosthetic appliance due to loss or theft. The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury, congenital defect, or alopecia as a result of chemotherapy, radiation therapy, and second or third degree burns. External prosthetic appliances shall include artificial arms and legs, wigs, hair pieces and terminal devices such as a hand or hook. Wigs and hair pieces are limited to one per Plan Year. Members must provide a valid prescription verifying diagnosis of alopecia as a result of chemotherapy, radiation therapy, second or third degree burns with a submitted claim for coverage. All other diagnosis are excluded. Replacement of artificial arms and legs and terminal devices are covered only if necessitated by normal anatomical growth or as a result of wear and tear.
Infusion Therapy
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% Infusion/IV Therapy in an Outpatient setting including, but not limited to: Infliximab (Remicade), Alefacept (Amevive), and Etanercept (Enbrel).
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder which is a result of: 1. An accident; 2. Trauma; 3. A congenital defect; 4. A developmental defect; or 5. A pathology.
Nutritional Counseling
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% Covered when dietary adjustment has a therapeutic role of a diagnosed chronic disease/condition, including but not limited to: 1. Morbid obesity 2. Diabetes 3. Cardiovascular disease 4. Hypertension 5. Kidney disease 6. Eating disorders 7. Gastrointestinal disorders 8. Food allergies 9. Hyperlipidemia
Reconstructive Surgery
Covered
Not Applicable 30% Coinsurance after deductibleNot Applicable 100.00% Following a mastectomy, the following services and supplies are covered: 1. Surgical services for reconstruction of the breast on which the mastectomy was performed; 2. Surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance; 3. Post-operative breast prostheses; and 4. Mastectomy bras/camisoles and external prosthetics that meet external prosthetic placement needs. During all stages of mastectomy, treatments of physical complications, including lymphedema, are covered. Cosmetic Surgery is covered for reconstructive surgery that constitutes necessary care and treatment of medically diagnosed services required for the prompt repair of accidental injury. Congenital defects and birth abnormalities are covered for Eligible Dependent children.
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following UHC Bronze Value HSA 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 UHC Bronze Value HSA 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 UHC Bronze Value HSA?

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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