Saint Francis Expanded Bronze Standardized

CommunityCare

Expanded BronzeHSA eligible

Ind. deductible: $7,500
Family deductible: $7,500
Ind. OOP max: $10,000
Family OOP max: $10,000

Other cost-sharing reduction variants for this plan:

Limited Cost Sharing Plan Variation Standard Bronze Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$363	—
30	$412	—
40	$464	—
50	$649	—
60	$986	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	0.00%
Primary Care Visit to Treat an Injury or Illness	$0.00

Specialist

Benefit	In-network
Specialist Visit	$100.00

Hospital

Benefit	In-network
Emergency Room Services	No charge
Inpatient Hospital Services (e.g., Hospital Stay)	50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	$0.00
Urgent Care Centers or Facilities	$75.00

Pharmacy

Benefit	In-network
Generic Drugs	$0.00
Non-Preferred Brand Drugs	$100.00 Copay after deductible
Preferred Brand Drugs	$50.00 Copay after deductible
Specialty Drugs	$500.00 Copay after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services	$50.00

Other

Benefit	In-network
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	50.00% Coinsurance after deductible
Acupuncture	Not covered
Allergy Testing	50.00% Coinsurance after deductible
Bariatric Surgery	Not covered
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	Not covered
Chemotherapy	50.00% Coinsurance after deductible
Chiropractic Care	$100.00
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	50.00% Coinsurance after deductible
Dental Check-Up for Children	Not covered
Diabetes Education	No charge
Dialysis	$0.00
Durable Medical Equipment	50.00% Coinsurance after deductible
Emergency Transportation/Ambulance	50.00% Coinsurance after deductible
Eye Glasses for Children	50.00% Coinsurance after deductible
Habilitation Services	$50.00
Hearing Aids	50.00% Coinsurance after deductible
Home Health Care Services	$0.00
Hospice Services	No charge
Imaging (CT/PET Scans, MRIs)	50.00% Coinsurance after deductible
Infertility Treatment	Not covered
Infusion Therapy	50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	Not covered
Nutritional Counseling	50.00% Coinsurance after deductible
Orthodontia - Adult	Not covered
Orthodontia - Child	Not covered
Other Practitioner Office Visit (Nurse, Physician Assistant)	$50.00
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	50.00% Coinsurance after deductible
Outpatient Rehabilitation Services	$0.00
Prenatal and Postnatal Care	No charge
Private-Duty Nursing	$0.00
Prosthetic Devices	50.00% Coinsurance after deductible
Radiation	50.00% Coinsurance after deductible
Reconstructive Surgery	$0.00
Rehabilitative Occupational and Rehabilitative Physical Therapy	$50.00
Rehabilitative Speech Therapy	$50.00
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Routine Eye Exam for Children	No charge
Routine Foot Care	Not covered
Skilled Nursing Facility	50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services	50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	$0.00
Transplant	50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders	Not covered
Weight Loss Programs	Not covered
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	50.00% Coinsurance after deductible

Plan rules

Service area

This plan covers 4 geographic areas.