Piedmont Community Healthcare HMO, Inc health insurance plan with the Plan ID 37204VA0080005. The plan is called Piedmont Bronze 5500 HSA.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.28% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.72% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
Health Insurance Plan ID | 37204VA0080005 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Virginia | ||||||||||||||||||
Health Insurance Issuer | Piedmont Community Healthcare HMO, Inc | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 37204VA0080005-00 | ||||||||||||||||||
Provider Network(s) | ['VAN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 01 Oct 2024 06:11 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 37204VA0080005-00 Standard On Exchange Plan - 37204VA0080005-01 |
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Last Plan Update Date | Tue, 16 Aug 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 01 Oct 2024 06:11 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
Exclusions: Damage to your teeth due to chewing or biting is not deemed an accidental injury and is not covered. Includes dental work, to include oral/surgical correction needed to treat injuries to the jaw, sound natural teeth, mouth or face as a result of an accident. Dental appliances required to diagnose or treat an accidental injury to the teeth, and the repair of dental appliances damaged as a result of accidental injury to the jaw, mouth or face, are also covered. Treatment must begin within 12 months of the injury, or as soon after that as possible to be a covered service. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
Includes benefits for medically necessary allergy testing and treatment, including allergy serum and allergy shots. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Chemotherapy
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
Limit: 30.0 Visit(s) per Benefit Period Exclusions: Spinal manipulations or other manual medical interventions for an illness or injury other than musculoskeletal conditions. Includes therapy to treat problems of the bones, joints, joints of the spine, the nervous system, and the back, and osteopathic therapy which focuses on the joints and surrounding muscles, tendons and ligaments. The visit limit applies separately for habilitative and rehablitative services. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
Exclusions: Services related to surrogacy if member is not the surrogate Includes services needed during a normal or complicated pregnancy and for services needed for a miscarriage. Covered maternity services include: pregnancy testing; professional and facility services for childbirth including use of the delivery room and care for normal deliveries, in a facility or the home including the services of an appropriately licensed nurse midwife; anesthesia services to provide partial or complete loss of sensation before delivery; routine nursery care for the newborn during the mother?s normal hospital stay, including circumcision of a covered male dependent; allowed fetal screenings, which are genetic or chromosomal tests of the fetus. Hospital stay for childbirth for mother and newborn may not be limited to less than 48 hours after vaginal birth or less than 96 hours after a cesarean section, unless the mother and attending provider request it. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Education
Includes education for diabetes care for all diabetics, including outpatient self-management training and education performed in-person; medical nutrition therapy, when provided by a certified, licensed, or registered health care professional. Diabetic education may be received from pharmacies that are authorized to perform this service. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Dialysis
Includes services for acute renal failure and chronic (end-stage) renal disease, including hemodialysis, home intermittent peritoneal dialysis (IPD), home continuous cycling peritoneal dialysis (CCPD), and home continuous ambulatory peritoneal dialysis (CAPD). Dialysis treatments can be rendered in an outpatient dialysis Facility, doctor?s office, or home dialysis and training for the covered person and the person who will help with home self-dialysis. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
Exclusions: Those items that have both a therapeutic and non-therapeutic use including exercise equipment, air conditioners, dehumidifiers, humidifiers and purifiers, hypoallergenic bed linens, whirlpool baths, handrails, ramps, elevators, stair glides, telephones, adjustments made to a vehicle, foot orthotics, changes made to home or place of business, repair or replacement of equipment lost or damaged through neglect. Over the counter convenience and hygiene items that include but are not limited to adhesive removers, cleansers, underpads, and ice. Includes Medical Devices, Orthotics, Medical and Surgical Supplies. Benefits include equipment and devices (e.g., crutches and customized equipment, Hospital beds and wheelchairs, oxygen concentrator, ventilator, and negative pressure, wound therapy devices). Coverage for ongoing rental of equipment may be limited to the cost of purchasing the equipment. Benefits include repair and replacement costs as well as supplies and equipment needed for the use of the equipment or device, for example, a battery for a powered wheelchair. Oxygen and equipment for its administration are also covered services. Benefits are also available for cochlear implants. Benefits are available for certain types of orthotics (braces, boots, and splints). Covered Services include the initial purchase, fitting, and repair of a custom made rigid or semi-rigid supportive device used to support, align, prevent, or correct deformities or to improve the function of movable parts of the body, or which limits or stops motion of a weak or diseased body part. Also, includes coverage for devices and supplies, such as APAP, CPAP, BPAP and oral devices for sleep treatment, subject to medical necessity. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
Benefits are available in a Hospital Emergency Room, or an independent, free-standing emergency facility, for services and supplies to treat the onset of symptoms for a medical emergency. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
Includes medically necessary transportation to the nearest appropriate hospital for a medical emergency, or between hospitals or other approved facilities. Includes ground, water, fixed wing and rotary air transportation. Benefits also include medically necessary treatment of a sickness or injury by medical professionals from an ambulance service, even if you are not taken to a facility. Benefits are only available for air ambulance when it is not appropriate to use a ground or water ambulance. |
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Includes a choice of eyeglass lenses with factory scratch coating or contact lenses in one benefit period. Covered eyeglass lenses include standard plastic (CR39) lenses up to 55mm in: Single vision; Bifocal; Trifocal (FT 25-28); and Progressive. Members choose from a limited frame selection. Coverage for contact lenses includes elective or non-elective contact lenses. Non-elective contact lenses are covered only for the following medical conditions: Keratoconus when your vision is not correctable to 20/40 in either or both eyes using standard spectacle lenses; High Ametropia exceeding -12D or +9D in spherical equivalent; Anisometropia of 3D or more; when your vision can be corrected three lines of improvement on the visual acuity chart when compared to best corrected standard spectacle lenses. |
YES | No Charge |
100.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
Exclusions: Over-the-Counter drugs are not covered unless recommended by the US Preventive Services Task Force and prescribed by a physician; drugs used mainly for cosmetic purposes; drugs for weight loss; nutritional and/or dietary supplements are not covered except as described in the policy booklet or as required by law. Covers prescription legend drugs from either a Retail Pharmacy or the PBM?s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: Group or individual exercise classes or personal training sessions; recreational therapy (dance, arts, crafts, aquatic, gambling and nature therapy), except as provided in a residential treatment facility. Benefits that help you keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn?t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, medical devices, and other services for people with disabilities in a variety of inpatient and/or outpatient settings. See individual therapy limits. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Hearing Aids
|
NO | ||
Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period Exclusions: Homemaker services; food and home-delivered meals; custodial care and services Visit limit does not apply to home infusion therapy or home dialysis. The Home Care visit limit will apply instead of the Therapy Services limits for physical, occupational, speech therapy, or cardiac rehabilitation for therapy in the home. Benefit includes intermittent skilled nursing services by an R.N. or L.P.N.; Medical/social services; Diagnostic services; Nutritional guidance; Training of the patient and/or family/caregiver; Home health aide services; Therapy Services; Medical supplies; Durable medical equipment. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Hospice Services
Short-term Inpatient Hospital care when needed in periods of crisis or as respite care. Skilled nursing services, home health aide services, and homemaker/custodial care services given by or under the supervision of a registered nurse. Social services and counseling services from a licensed social worker. Nutritional support such as intravenous feeding and feeding tubes. Physical therapy, occupational therapy, speech therapy, and respiratory therapy given by a licensed therapist. Pharmaceuticals, medical equipment, and supplies needed for pain management and the palliative care of your condition, including oxygen and related respiratory therapy supplies. Bereavement (grief) services, including a review of the needs of the bereaved family and the development of a care plan to meet those needs, both before and after the Member?s death. Bereavement services are available to surviving Members of the immediate family for one year after the Member?s death. Immediate family means your spouse, children, stepchildren, parents, brothers and sisters. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
Includes x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine; and advanced imaging, including CT scan, CTA scan, Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiography (MRA); Magnetic Resonance Spectroscopy (MRS); Nuclear Cardiology; PET scans; PET/CT Fusion scans; QTC Bone Densitometry; Diagnostic CT Colonography; Single photon emission computed tomography (SPCECT) scans. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
Includes nursing, durable medical equipment and drug services that are delivered and administered to you through an I.V. in your home. Also includes Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain care and chemotherapy. May include injections (intra-muscular, subcutaneous, continuous subcutaneous). Also covers prescription drugs when they are administered to you as part of a doctor?s visit, home care visit, or at an outpatient Facility. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: Convenience items; Private room unless medically necessary; Oral surgery that is dental in origin; Removal of impacted wisdom teeth; Reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects Benefits for room, board, and nursing services include: a room with two or more beds; a private room when medically necessary for isolation and no isolation facilities are available; a room in an approved special care unit; meals, special diets; general nursing services; operating, childbirth, and treatment rooms and equipment; prescribed drugs; anesthesia, anesthesia supplies and services given by the hospital or other provider; medical and surgical dressings and supplies, casts, and splints; blood and blood products; diagnostic services. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
Includes medical care visits; intensive medical care when medically necessary; treatment for a health problem by a Doctor who is not your surgeon while you are in the Hospital for surgery; treatment by two or more Doctors during one Hospital stay when the nature or severity of your health problem calls for the skill of separate Doctors; a personal bedside exam by another Doctor when asked for by your Doctor; surgery and general anesthesia; professional charges to interpret diagnostic tests such as imaging, pathology reports, and cardiology. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when medically necessary; medically necessary pre-operative and post-operative care. Medical benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is medically necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
NO | ||
Mental/Behavioral Health Inpatient Services
Includes services in a hospital or any facility required to be covered by state law. Inpatient benefits include individual psychotherapy, group psychotherapy, psychological testing, counseling with family members to assist with the patient?s diagnosis and treatment, convulsive therapy, detoxification, and rehabilitation. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
Includes office visits, individual psychotherapy, group psychotherapy, psychological testing, and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law. For treatment in an outpatient department of a hospital or an outpatient facility, please refer to the Outpatient Facility benefit. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Non-Preferred Brand Drugs
Exclusions: Over-the-Counter drugs are not covered unless recommended by the US Preventive Services Task Force and prescribed by a physician; drugs used mainly for cosmetic purposes; drugs for weight loss; nutritional and/or dietary supplements are not covered except as described in the policy booklet or as required by law. Covers prescription legend drugs from either a Retail Pharmacy or the PBM?s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Nutritional Counseling
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: Non-interactive telemedicine services Includes Retail Health Clinics (walk-ins). |
YES | 35.00% Coinsurance after deductible |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: Oral surgery that is dental in origin; Reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects. Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care. Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: Group or individual exercise classes or personal training sessions; recreational therapy (dance, arts, crafts, aquatic, gambling and nature therapy), except as provided in a residential treatment facility. Benefits are based on the setting in which covered services are received. See individual therapy limits. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
Exclusions: Oral surgery that is dental in origin; Reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects. Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or outpatient surgery facility. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care. Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
Exclusions: Over-the-Counter drugs are not covered unless recommended by the US Preventive Services Task Force and prescribed by a physician; drugs used mainly for cosmetic purposes; drugs for weight loss; nutritional and/or dietary supplements are not covered except as described in the policy booklet or as required by law. Covers prescription legend drugs from either a Retail Pharmacy or the PBM?s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Prenatal and Postnatal Care
Exclusions: Services related to surrogacy if member is not the surrogate Includes prenatal and postnatal services for the mother; postnatal services for the baby, including hemoglobinopathies screening; gonorrhea prophylactic medication; hypothyroidism screening, PKY screening and Rh incompatibility testing. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
Covers: (1) Services with an 'A' or 'B' rating from the United States Preventive Services Task Force; (2) Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; (3) Preventive care and screenings for infants, children and adolescents as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening); (4) Preventive care and screening for women as listed in the guidelines supported by the Health Resources and Services Administration; and (5) Counseling services related to nutrition, and to smoking and tobacco use cessation. Prescription drugs that help you stop smoking or reduce your dependence on tobacco products are also covered preventive services. Smoking cessation products and over the counter nicotine replacement products (limited to nicotine patches and gum) are covered when obtained with a prescription. Additionally, state law requires coverage for routine screening mammograms and routine prostate specific antigen testing and digital rectal exams. |
YES | No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
Exclusions: Non-interactive telemedicine services Including doctor visits in the home and online visits. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Private-Duty Nursing
Limit: 16.0 Hours per Benefit Period |
YES | 35.00% Coinsurance after deductible |
100.00% |
Prosthetic Devices
Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Coverage is also included for the repair, fitting, adjustments and replacement of a prosthetic device. In additional, components for artificial limbs are covered. Components are the materials and equipment needed to ensure the comfort and functioning of the prosthetic device. Covered services may include: 1) Artificial limbs and components (the materials and equipment needed to ensure the comfort and functioning of the prosthetic device); 2) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Women?s Health and Cancer Rights Act. 3) Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to ostomy care. 4) Restoration prosthesis (composite facial prosthesis) 5) Wigs needed after cancer treatment (limited to one wig per benefit period). |
YES | 30.00% Coinsurance after deductible |
100.00% |
Radiation
Includes treatment (tele therapy, brachytherapy and intraoperative radiation, photon or high-energy particle sources), materials and supplies needed, administration, and treatment planning. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
Includes reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Also includes surgery performed to restore symmetry after a mastectomy. Reconstructive services needed as a result of an earlier treatment are covered only if the first treatment would have been a covered service. Hospital admissions for covered radical or modified radical mastectomy for the treatment of breast cancer shall be approved for a period of no less than 48 hours. Hospital admissions for a covered total or partial mastectomy with lymph node dissection for the treatment of breast cancer shall be approved for a period of no less than 24 hours. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period Includes treatment to restore a physically disabled person?s ability to do activities of daily living, such as walking, eating, drinking, dressing, using the toilet, moving from a wheelchair to a bed, bathing, and therapy for tasks needed for the person?s job. Also, includes the treatment by physical means to ease pain, restore health, and to avoid disability after an illness, injury, or loss of an arm or a leg by means of hydrotherapy, heat, physical agents, bio-mechanical and neuro-physiological principles and devices. Limit does not apply when received as part of hospice benefit, early intervention benefit, or for autism spectrum disorder. The visit limit applies separately for habilitative and rehablitative services. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period Includes services to identify, assess, and treat speech, language, and swallowing disorders in children and adults. Therapy will develop or treat communication or swallowing skills to correct a speech impairment. Limit does not apply when received as part of hospice benefit, or early intervention benefit, or for autism spectrum disorder. The visit limit applies separately for habilitative and rehablitative services. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period Includes complete eye exam with dilation, as needed to check all aspects of vision, including the structure of the eyes and how well they work together. |
YES | No Charge |
100.00% |
Routine Foot Care
|
NO | ||
Skilled Nursing Facility
Limit: 100.0 Days per Stay Exclusions: Custodial or residential care in a skilled nursing facility or any other facility is not covered except as rendered as part of Hospice care Includes room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies. Your Plan will cover the private room charge when medically necessary. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Specialist Visit
Exclusions: Non-interactive telemedicine services |
YES | 35.00% Coinsurance after deductible |
100.00% |
Specialty Drugs
Exclusions: Over-the-Counter drugs are not covered unless recommended by the US Preventive Services Task Force and prescribed by a physician; drugs used mainly for cosmetic purposes; drugs for weight loss; nutritional and/or dietary supplements are not covered except as described in the policy booklet or as required by law. Covers prescription legend drugs from either a Retail Pharmacy or the PBM?s Home Delivery Pharmacy; self-administered injectable drugs; specialty drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
Includes services in a hospital or any facility required to be covered by state law. Inpatient benefits include individual psychotherapy, group psychotherapy, psychological testing, counseling with family members to assist with the patient?s diagnosis and treatment, convulsive therapy, detoxification, and rehabilitation. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
Includes office visits, individual psychotherapy, group psychotherapy, psychological testing, and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law. For treatment in an outpatient department of a hospital or an outpatient facility, please refer to the Outpatient Facility benefit. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Transplant
Includes coverage for medically necessary human organ, tissue, and stem cell/bone marrow transplants and infusions including necessary acquisition procedures, mobilization, harvest and storage. It also includes medically necessary myeloablative or reduced intensity preparative chemotherapy, radiation therapy, or a combination of these therapies. When a human organ transplant is provided from a living donor to a covered member, both the recipient and the donor may receive benefits. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
Exclusions: Does not cover appliances for TMJ pain dysfunction. Includes services to treat temporomandibular and craniomandibular disorders, such as removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. Dental benchmark plan covers occlusal orthotic devices for temporomandibular pain, dysfunction or associated musculature. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
Includes X-ray services; Care for broken bones; Tests such as flu, urinalysis, allergy test, pregnancy test, rapid strep; Lab services; Stitches for simple cuts; and Draining an abscess. |
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
Includes immunizations for children recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening). |
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
Includes benefits for tests or procedures to find or check a condition when specific symptoms exist, as well as benefits for interpretation of diagnostic tests such as imaging, and cardiology. Tests must be ordered by a Provider and include diagnostic services ordered before a surgery or Hospital admission. Benefits include the following services: x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.642781956 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Bronze Off Exchange Plan |
Dental Only Plan | No |
Design Type | Not Applicable |
Disease Management Programs Offered | Heart Disease, Diabetes |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 100% |
Formulary ID | VAF005 |
Formulary URL | URL |
HIOS Product ID | 37204VA008 |
Import Date | 8/16/2022 20:01 |
Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
Inpatient Copayment Maximum Days | 0 |
HSA Eligible | Yes |
New/Existing Plan | Existing |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
Issuer ID | 37204 |
Issuer Marketplace Marketing Name | Piedmont Community HealthCare HMO, Inc. |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Expanded Bronze |
Multiple In Network Tiers | No |
National Network | No |
Network ID | VAN001 |
Out of Country Coverage | No |
Out of Service Area Coverage | No |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 37204VA0080005-00 |
Plan Level Exclusions | No |
Plan Marketing Name | Piedmont Bronze 5500 HSA |
Plan Type | HMO |
Plan Variant Marketing Name | Piedmont Bronze 5500 HSA OFF |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $1,700 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $5,500 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $500 |
SBC Scenario, Having Diabetes, Deductible | $2,300 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | VAS001 |
Source Name | SERFF |
Plan ID | 37204VA0080005 |
State Code | VA |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 35.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $11000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5500 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,500 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $14400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7200 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,200 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
Unique Plan Design | No |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
---|
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 01 Oct 2024 06:11 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API