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		Standard Bronze ST OON IHC Network Marketplace Dep25

Price Per Month	$521.90	Metal	Bronze	Overall Quality Rating	Quality Details
Maximum Out of Pocket	$9,450 / $9450 per person \| $18900 per group	Out-of-Network Coverage	Yes	Allows Health Savings Account	No
Plan Id	18029NY1310016	Persons Covered	individual	Deductible	$4,600 / $4600 per person \| $9200 per group
Specialist(s) Referral Required No

Design	This plan does not require referrals to access care. This plan offers the full Independent Health network. Three Primary or Specialty Care visits are covered before the deductible; you pay only the copay. The deductible applies per person (embedded). The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition: earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. Members ages 18 and over can additionally earn up to $30 in rewards for completing health-related activities.

Design

This plan does not require referrals to access care. This plan offers the full Independent Health network. Three Primary or Specialty Care visits are covered before the deductible; you pay only the copay. The deductible applies per person (embedded). The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition: earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. Members ages 18 and over can additionally earn up to $30 in rewards for completing health-related activities.

Click on the benefit categories below to learn more about this plan's covered benefits and services. To see a full list of the benefits and services, visit the "Summary of Benefits" link under "Plan Documents" at the bottom of this page.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Outpatient Rehabilitation Services	$50.00 Copay after deductible	50.00% Coinsurance after deductible	60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.
Prosthetic Devices	50.00% Coinsurance after deductible	50.00% Coinsurance after deductible	One external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices)
Chiropractic Care	$75.00 Copay after deductible	50.00% Coinsurance after deductible	Care performed by a Doctor of Chiropractic (Chiropractor).
Durable Medical Equipment	50.00% Coinsurance after deductible	50.00% Coinsurance after deductible	Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Inpatient Rehabilitation Services	$1500.00 Copay after deductible	50.00% Coinsurance after deductible	Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services consist of physical therapy, occupational therapy, and speech therapy in an inpatient setting.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Wellness Benefit	Not Applicable	Not Applicable	Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. Members ages 18 and over can additionally earn up to $30 in rewards for completing health-related activities.
Prenatal and Postnatal Care	No Charge	50.00% Coinsurance after deductible	Healthcare for expectant mothers before and after the birth of their child.
Preventive Care/Screening/Immunization	No Charge	50.00% Coinsurance after deductible	Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Well Baby Visits and Care	No Charge	50.00% Coinsurance after deductible	Routine doctor visits for comprehensive preventive health services that occur when a baby is young.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Eye Glasses for Children	50.00% Coinsurance after deductible	Not Applicable	One prescribed lenses & frames in a 12-month period.
Routine Eye Exam for Children	$50.00 Copay after deductible	Not Applicable	Emergency, preventive and routine vision care for children.
Contact Lenses for Children	50.00% Coinsurance after deductible	Not Applicable	Standard prescription contact lenses once in any twelve (12) month period.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	$150.00 Copay after deductible	50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	$150.00 Copay after deductible	50.00% Coinsurance after deductible	Surgical services performed by a physician or surgeon in an outpatient facility.
Primary Care Visit to Treat an Injury or Illness	$50.00 Copay after deductible	50.00% Coinsurance after deductible	Visit to a clinician for health services that cover a range of prevention, wellness, and treatment for common illnesses.
Specialist Visit	$75.00 Copay after deductible	50.00% Coinsurance after deductible	Visits to a physician to diagnose, manage, prevent or treat certain types of symptoms and conditions related to a specific disease or condition.
Home Health Care Services	$50.00 Copay after deductible	50.00% Coinsurance after deductible	Each visit of up to four hours by a home health aide is one visit.
Other Practitioner Office Visit (Nurse, Physician Assistant)	$50.00 Copay after deductible	50.00% Coinsurance after deductible

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Preferred Brand Drugs	$35.00 Copay after deductible	Not Applicable	Brand drugs are sold by a drug company under a specific name or trademark and is protected by a patent. Preferred drugs are included on a plan's covered drug list or formulary.
Specialty Drugs	Not Applicable	Not Applicable	Specialty drugs are used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. The drugs are often self-injected or administered in a physician's office or through home health services.
Generic Drugs	$10.00 Copay after deductible	Not Applicable	A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs.
Non-Preferred Brand Drugs	$70.00 Copay after deductible	Not Applicable	Brand drugs are sold by a drug company under a specific name or trademark and is protected by a patent. Non-preferred drugs may or may not be included on a plan's covered drug list or formulary and have higher cost-share.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Second Opinion	$75.00 Copay after deductible	50.00% Coinsurance after deductible	A second medical opinion by an appropriate specialist or surgeon.
Telemedicine	No Charge	Not Applicable
Transplant	$1650.00 Copay after deductible	50.00% Coinsurance after deductible	Transplants determined to be nonexperimental and non-investigational. Covered transplants include but are not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome. NOTE: Cost-share shown is the combined amount, including both the surgical fee and the Inpatient cost-share.
Chemotherapy	$50.00 Copay after deductible	50.00% Coinsurance after deductible	Chemotherapy in an outpatient facility or in a Health Care Professional's office. Orally-administered anti-cancer drugs are covered under the prescription drug benefit.
Diabetic Equipment and Supplies	$50.00 Copay after deductible	50.00% Coinsurance after deductible
Family Planning Services	No Charge	50.00% Coinsurance after deductible	Counseling on the use of contraceptives, sterilization procedures, and related topics.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Skilled Nursing Facility	$1500.00 Copay per Stay after deductible	50.00% Coinsurance after deductible	A facility that performs skilled nursing care and rehabilitation services provided on a continuous, daily basis.
Delivery and All Inpatient Services for Maternity Care	$1650.00 Copay after deductible	50.00% Coinsurance after deductible	Delivery and inpatient maternity care in a hospital for the mother, and inpatient newborn care in a hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery.
Inpatient Hospital Services (e.g., Hospital Stay)	$1500.00 Copay per Stay after deductible	50.00% Coinsurance after deductible	Health care you get when you're admitted as a patient to a health care facility, like a hospital or skilled nursing facility.
Inpatient Physician and Surgical Services	$150.00 Copay after deductible	50.00% Coinsurance after deductible	Surgical services performed by a physician or surgeon in an inpatient facility.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Substance Abuse Disorder Inpatient Services	$1500.00 Copay per Stay after deductible	50.00% Coinsurance after deductible	Diagnosis and treatment of alcoholism and/or substance use and/or dependency in an inpatient setting. This includes coverage for detoxification and/or rehabilitation services as a consequence of chemical use and/or substance use.
Substance Abuse Disorder Outpatient Services	$50.00 Copay after deductible	50.00% Coinsurance after deductible	Also includes 20 visits per year for family counseling.
Applied Behavior Analysis Based Therapies	$50.00 Copay after deductible	50.00% Coinsurance after deductible	Design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis
Mental/Behavioral Health Inpatient Services	$1500.00 Copay per Stay after deductible	50.00% Coinsurance after deductible	Diagnosis and treatment of mental, nervous and emotional disorders performed in an inpatient setting.
Mental/Behavioral Health Outpatient Services	$50.00 Copay after deductible	50.00% Coinsurance after deductible	Diagnosis and treatment of mental, nervous and emotional disorders performed in an outpatient setting.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Urgent Care Centers or Facilities	$75.00 Copay after deductible	$75.00 Copay after deductible	A licensed facility (except Hospitals) that provides care for an illness, injury or condition serious enough to require care right away, but not so severe as to require emergency room care.
Emergency Room Services	$500.00 Copay after deductible	$500.00 Copay after deductible	Healthcare services you get in an emergency room.
Emergency Transportation/Ambulance	$300.00 Copay after deductible	$300.00 Copay after deductible	Ambulance services for an emergency medical condition.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
X-rays and Diagnostic Imaging	$75.00 Copay after deductible	50.00% Coinsurance after deductible	X-rays and other technologies that doctors use in the diagnosis of a medical condition
Imaging (CT/PET Scans, MRIs)	$175.00 Copay after deductible	50.00% Coinsurance after deductible	Imaging technologies such as CT and PET Scans and MRIs that doctors use in the treatment of a medical condition
Laboratory Outpatient and Professional Services	$50.00 Copay after deductible	50.00% Coinsurance after deductible	Professional fees and services associated with laboratory work for diagnostic and treatment purposes.

		Standard Bronze ST OON IHC Network Marketplace Dep25

Price Per Month	$521.90	Metal	Bronze	Overall Quality Rating
Quality Measure	Plan Administration	Rating		Description	Based on certain measures of how well a plan is run, including customer service, access to needed information, and network providers ordering appropriate testing and treatment.
Quality Measure	Medical Care	Rating		Description	Based on the plan's network providers improving or maintaining the health of its members with regular screenings, tests, vaccines, and monitoring of some conditions.
Quality Measure	Member Experience	Rating		Description	Based on member satisfaction surveys about their health care, doctors, and ease of getting appointments and services.
Maximum Out of Pocket	$9,450 / $9450 per person \| $18900 per group	Out-of-Network Coverage	Yes	Allows Health Savings Account	No
Plan Id	18029NY1310016	Persons Covered	individual	Deductible	$4,600 / $4600 per person \| $9200 per group
Specialist(s) Referral Required	No

Design	This plan does not require referrals to access care. This plan offers the full Independent Health network. Three Primary or Specialty Care visits are covered before the deductible; you pay only the copay. The deductible applies per person (embedded). The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a choice between fitness or nutrition: earn up to $250 for use at participating gym and wellness providers OR earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. Members ages 18 and over can additionally earn up to $30 in rewards for completing health-related activities.

Design

Rehabilitative and Habilitative Services and Devices

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Outpatient Rehabilitation Services	$50.00 Copay after deductible	50.00% Coinsurance after deductible	60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.
Prosthetic Devices	50.00% Coinsurance after deductible	50.00% Coinsurance after deductible	One external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices)
Chiropractic Care	$75.00 Copay after deductible	50.00% Coinsurance after deductible	Care performed by a Doctor of Chiropractic (Chiropractor).
Durable Medical Equipment	50.00% Coinsurance after deductible	50.00% Coinsurance after deductible	Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Inpatient Rehabilitation Services	$1500.00 Copay after deductible	50.00% Coinsurance after deductible	Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services consist of physical therapy, occupational therapy, and speech therapy in an inpatient setting.

Preventive and Wellness Services and Chronic Disease Management

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Wellness Benefit	Not Applicable	Not Applicable	Earn up to $250 for use at participating gym and wellness providers OR Earn rewards for purchase of fresh fruits and vegetables up to $500/$1,000 at participating grocery stores. Members ages 18 and over can additionally earn up to $30 in rewards for completing health-related activities.
Prenatal and Postnatal Care	No Charge	50.00% Coinsurance after deductible	Healthcare for expectant mothers before and after the birth of their child.
Preventive Care/Screening/Immunization	No Charge	50.00% Coinsurance after deductible	Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Well Baby Visits and Care	No Charge	50.00% Coinsurance after deductible	Routine doctor visits for comprehensive preventive health services that occur when a baby is young.

Pediatric Vision

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Eye Glasses for Children	50.00% Coinsurance after deductible	Not Applicable	One prescribed lenses & frames in a 12-month period.
Routine Eye Exam for Children	$50.00 Copay after deductible	Not Applicable	Emergency, preventive and routine vision care for children.
Contact Lenses for Children	50.00% Coinsurance after deductible	Not Applicable	Standard prescription contact lenses once in any twelve (12) month period.

Outpatient Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	$150.00 Copay after deductible	50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	$150.00 Copay after deductible	50.00% Coinsurance after deductible	Surgical services performed by a physician or surgeon in an outpatient facility.
Primary Care Visit to Treat an Injury or Illness	$50.00 Copay after deductible	50.00% Coinsurance after deductible	Visit to a clinician for health services that cover a range of prevention, wellness, and treatment for common illnesses.
Specialist Visit	$75.00 Copay after deductible	50.00% Coinsurance after deductible	Visits to a physician to diagnose, manage, prevent or treat certain types of symptoms and conditions related to a specific disease or condition.
Home Health Care Services	$50.00 Copay after deductible	50.00% Coinsurance after deductible	Each visit of up to four hours by a home health aide is one visit.
Other Practitioner Office Visit (Nurse, Physician Assistant)	$50.00 Copay after deductible	50.00% Coinsurance after deductible

Prescription Drugs

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Preferred Brand Drugs	$35.00 Copay after deductible	Not Applicable	Brand drugs are sold by a drug company under a specific name or trademark and is protected by a patent. Preferred drugs are included on a plan's covered drug list or formulary.
Specialty Drugs	Not Applicable	Not Applicable	Specialty drugs are used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. The drugs are often self-injected or administered in a physician's office or through home health services.
Generic Drugs	$10.00 Copay after deductible	Not Applicable	A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs.
Non-Preferred Brand Drugs	$70.00 Copay after deductible	Not Applicable	Brand drugs are sold by a drug company under a specific name or trademark and is protected by a patent. Non-preferred drugs may or may not be included on a plan's covered drug list or formulary and have higher cost-share.

Other Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Second Opinion	$75.00 Copay after deductible	50.00% Coinsurance after deductible	A second medical opinion by an appropriate specialist or surgeon.
Telemedicine	No Charge	Not Applicable
Transplant	$1650.00 Copay after deductible	50.00% Coinsurance after deductible	Transplants determined to be nonexperimental and non-investigational. Covered transplants include but are not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome. NOTE: Cost-share shown is the combined amount, including both the surgical fee and the Inpatient cost-share.
Chemotherapy	$50.00 Copay after deductible	50.00% Coinsurance after deductible	Chemotherapy in an outpatient facility or in a Health Care Professional's office. Orally-administered anti-cancer drugs are covered under the prescription drug benefit.
Diabetic Equipment and Supplies	$50.00 Copay after deductible	50.00% Coinsurance after deductible
Family Planning Services	No Charge	50.00% Coinsurance after deductible	Counseling on the use of contraceptives, sterilization procedures, and related topics.

Hospitalization

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Skilled Nursing Facility	$1500.00 Copay per Stay after deductible	50.00% Coinsurance after deductible	A facility that performs skilled nursing care and rehabilitation services provided on a continuous, daily basis.
Delivery and All Inpatient Services for Maternity Care	$1650.00 Copay after deductible	50.00% Coinsurance after deductible	Delivery and inpatient maternity care in a hospital for the mother, and inpatient newborn care in a hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery.
Inpatient Hospital Services (e.g., Hospital Stay)	$1500.00 Copay per Stay after deductible	50.00% Coinsurance after deductible	Health care you get when you're admitted as a patient to a health care facility, like a hospital or skilled nursing facility.
Inpatient Physician and Surgical Services	$150.00 Copay after deductible	50.00% Coinsurance after deductible	Surgical services performed by a physician or surgeon in an inpatient facility.

Mental Health and Substance Abuse Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Substance Abuse Disorder Inpatient Services	$1500.00 Copay per Stay after deductible	50.00% Coinsurance after deductible	Diagnosis and treatment of alcoholism and/or substance use and/or dependency in an inpatient setting. This includes coverage for detoxification and/or rehabilitation services as a consequence of chemical use and/or substance use.
Substance Abuse Disorder Outpatient Services	$50.00 Copay after deductible	50.00% Coinsurance after deductible	Also includes 20 visits per year for family counseling.
Applied Behavior Analysis Based Therapies	$50.00 Copay after deductible	50.00% Coinsurance after deductible	Design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis
Mental/Behavioral Health Inpatient Services	$1500.00 Copay per Stay after deductible	50.00% Coinsurance after deductible	Diagnosis and treatment of mental, nervous and emotional disorders performed in an inpatient setting.
Mental/Behavioral Health Outpatient Services	$50.00 Copay after deductible	50.00% Coinsurance after deductible	Diagnosis and treatment of mental, nervous and emotional disorders performed in an outpatient setting.

Emergency Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Urgent Care Centers or Facilities	$75.00 Copay after deductible	$75.00 Copay after deductible	A licensed facility (except Hospitals) that provides care for an illness, injury or condition serious enough to require care right away, but not so severe as to require emergency room care.
Emergency Room Services	$500.00 Copay after deductible	$500.00 Copay after deductible	Healthcare services you get in an emergency room.
Emergency Transportation/Ambulance	$300.00 Copay after deductible	$300.00 Copay after deductible	Ambulance services for an emergency medical condition.

Laboratory Outpatient and Professional Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
X-rays and Diagnostic Imaging	$75.00 Copay after deductible	50.00% Coinsurance after deductible	X-rays and other technologies that doctors use in the diagnosis of a medical condition
Imaging (CT/PET Scans, MRIs)	$175.00 Copay after deductible	50.00% Coinsurance after deductible	Imaging technologies such as CT and PET Scans and MRIs that doctors use in the treatment of a medical condition
Laboratory Outpatient and Professional Services	$50.00 Copay after deductible	50.00% Coinsurance after deductible	Professional fees and services associated with laboratory work for diagnostic and treatment purposes.

Plan Documents

Customer Service	https://www.independenthealth.com
Summary of Benefits and Coverage	https://www.independenthealth.com/Exchange/Benefits?yr=2024&hios=18029NY131001601
Prescription Drug List	https://fm.formularynavigator.com/FBO/43/2024DrugFormulary2.pdf
Provider Network	https://www.independenthealth.com/IndividualsFamilies/FindADoctor
Plan Brochure	https://www.independenthealth.com/Exchange/Benefits?yr=2024&hios=18029NY131001601
Payment Information	https://www.independenthealth.com/IndividualsFamilies/ToolsFormsMore/MakeaOne-TimePayment

Plan Details