New York's Insurance Marketplace Plans in Monroe County*
BRONZE
$3,000
Deductible - Individual
Out of Pocket - Individual
Policy Maximum
$6,350
Unlimited
Preventative Care
SILVER
$2,000
GOLD
$600
PLATINUM
None
$5,500
$4,000
$2,000
Unlimited
Unlimited
Unlimited
No Cost - 100% Insurance Coverage for In-Network Benefits
RIT
None
$6,350
Unlimited
Primary Care Office Visit
50% after ded.
$30 copay after ded.
$25 copay after ded.
$15 copay
90%
Specialist Office Visit
50% after ded.
$50 copay after ded.
$40 copay after ded.
$35 copay
90%
Physical/Occupational Therapy
50% after ded.
$30 copay after ded.
$30 copay after ded.
$25 copay
90%
Lab and X-ray
50% after ded.
PCP Office: $30 copay after ded.
Lab facility/Outpatient Hospital: $50
copay after ded.
PCP Office: $25 copay after ded.
Lab facility/Outpatient Hospital:
$40 copay after ded.
PCP Office: $15 copay
Lab facility/Outpatient
Hospital: $35 copay
90%
Allergy Testing
50% after ded.
PCP Office: $30 copay after ded.
Lab facility/Outpatient Hospital: $50
copay after ded.
PCP Office: $25 copay after ded.
Lab facility/Outpatient Hospital:
$40 copay after ded.
PCP Office: $15 copay
Lab facility/Outpatient
Hospital: $35 copay
same as any other condition
Emergency Care
50% after ded.
$150 copay after ded.
$150 copay after ded.
$100 copay
90%
Urgent Care
50% after ded.
$70 copay after ded.
$150 copay after ded.
$55 copay
Ambulance
50% after ded.
50% after ded.
Inpatient Medical
50% after ded.
$150 copay after ded.
$100 copay
$100 copay after ded.
$100 copay
Office setting: $25 (PCP)/$40
Office setting: $15 (PCP)/$35
(Specialist) after ded.
(Specialist)
$1,000 per admission after ded.
$500 per admission
90%
90%
Surgery
$150 copay after ded.
$100 copay after ded.
Office setting: $30 (PCP)/$50
(Specialist) after ded.
$1,500 per admission after ded.
Maternity
50% after ded.
$1,500 per admission after ded.
$1,000 per admission after ded.
$500 per admission
Inpatient Mental Health
50% after ded.
$1,500 per admission after ded.
$1,000 per admission after ded.
$500 per admission
90%
Outpatient Mental Health
50% after ded.
$30 copay after ded.
$25 copay after ded.
$15 copay
Inpatient Substance Abuse
50% after ded.
$1,500 per admission after ded.
$1,000 per admission after ded.
$500 per admission
90%
90%
Outpatient Substance Abuse
50% after ded.
$30 copay after ded.
$25 copay after ded.
$15 copay
Tier 1
$10
$10
$10
$10
90%
$10
Tier 2
$35
$35
$35
$30
$30
Tier 3
$70
$70
$70
$60
$30
$2,575-$4,397
$3,248-$5,455
$3,678-$6,277
$4,325-$7,038
$1,475
Prescription Drugs
Monroe Premium**
* The Covered Benefits and Out-of-Pocket Costs for Standard Health Plans offered on the New York Health Insurance Marketplace can be viewed online:
http://www.healthbenefitexchange.ny.gov/resource/covered-benefits-and-out-pocket-costs-standard-health-plans
** The Tax Credit and Premium Estimator can be accessed via the same link. The premiums above are for an individual who is not eligible for tax credits and is located in Monroe County. Subject to change as of January 1,
2015.
90%
90%
same as any other condition