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Medica with CHI Health Gold Copay
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Medica with CHI Health Gold Copay

Overview
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Medica with CHI Health Gold Copay is an individual health health plan issued by Medica Insurance Company and is available for the year 2019. This health plan is offered by the federal government through HealthCare.gov and the Affordable Care Act (ACA).

Where Do I Need to Live to Quality for this Plan?

This plan is available for qualifying individuals who live in Pawnee county, Nebraska.

What Type of Health Plan Is This?

This plan is an EPO plan, which is also known as an "Exclusive Provider Organization." An EPO is a managed care plan where services are covered so long as the the hospitals, dentists, and other health providers in the plan's network are used.

Where Can I Buy This Plan?

You can purchase this plan at HealthCare.gov.

About
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Issuer
Medica Insurance Company
Plan ID
20305NE0050001
Coverage area
Pawnee County, Nebraska
Phone
Local Phone: 1-888-592-8211
Toll-Free: 1-888-592-8211
TTY: 1-800-833-7352
Plan type
EPO
Coverage type
Medical deductible
$750
Out-of-pocket maximum
$6,500
Generic drug co-pay
$15
Preferred brand drug co-pay
$70
Primary care physician visit cost
$30
Specialist doctor visit cost
$60
Doctor Visits
Primary Care Visit $30
Specialist Visit $60
Emergency Room Visit 30% Coinsurance after deductible
Inpatient Facility Visit 30% Coinsurance after deductible
Inpatient Physician Visit 30% Coinsurance after deductible
Prescription Drugs
Generic Drugs $15
Preferred Brand Drugs $70
Non-preferred Brand Drugs 50% Coinsurance after deductible
Specialty Drugs $500
Medical Deductible
Medical Deductible (Individual) $750
Medical Maximum Out Of Pocket (Individual) $6,500
Medical Deductible (Family) $2,250
Medical Maximum Out Of Pocket (Family) $13,000
Drug Deductible
Drug Deductible (Individual) Included in Medical
Drug Maximum Out Of Pocket (Individual) Included in Medical
Drug Deductible (Family) Included in Medical
Drug Maximum Out Of Pocket (Family) Included in Medical
Premium Rates
EHB Percent of Total Premium 100.00%
Premium Child Age 0-14 320
Premium Child Age 18 382
Premium Adult Individual Age 21 418
Premium Adult Individual Age 27 438
Premium Adult Individual Age 30 475
Premium Adult Individual Age 40 534
Premium Adult Individual Age 50 747
Premium Adult Individual Age 60 1,135
Premium Couple 21 837
Premium Couple 30 950
Premium Couple 40 1,069
Premium Couple 50 1,495
Premium Couple 60 2,271
Couple+1 child, Age 21 1,157
Couple+1 child, Age 30 1,270
Couple+1 child, Age 40 1,390
Couple+1 child, Age 50 1,815
Couple+2 children, Age 21 1,477
Couple+2 children, Age 30 1,590
Couple+2 children, Age 40 1,710
Couple+2 children, Age 50 2,135
Couple+3 or more Children, Age 21 1,797
Couple+3 or more Children, Age 30 1,910
Couple+3 or more Children, Age 40 2,030
Couple+3 or more Children, Age 50 2,455
Individual+1 child, Age 21 738
Individual+1 child, Age 30 795
Individual+1 child, Age 40 855
Individual+1 child, Age 50 1,067
Individual+2 children, Age 21 1,058
Individual+2 children, Age 30 1,115
Individual+2 children, Age 40 1,175
Individual+2 children, Age 50 1,387
Individual+3 or more children, Age 21 1,379
Individual+3 or more children, Age 30 1,435
Individual+3 or more children, Age 40 1,495
Individual+3 or more children, Age 50 1,708
Reference
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  • HealthCare.gov. U.S. Centers for Medicare and Medicaid. Accessed June 11, 2019. https://www.healthcare.gov
  • The 'metal' categories: Bronze, Silver, Gold & Platinum. U.S. Centers for Medicare and Medicaid. Accessed June 11, 2019. https://www.healthcare.gov/choose-a-plan/plans-categories
  • Health insurance plan & network types: HMOs, PPOs, and more. U.S. Centers for Medicare and Medicaid. Accessed June 11, 2019. https://www.healthcare.gov/choose-a-plan/plan-types