MetroPlus small business Plans at‑a‑glance 2020 · 2019-11-14 · Hearing Aids (50%) Chiropractic ($50) & Hearing Aids (30%) Chiropractic ($40) & Hearing Aids (20%) Chiropractic

NY State of Health Marketplace plan

Bronze-B4, ST, INN, Pediatric Dental, Dep25, DP, FP

Silver-S4, ST, INN, Pediatric Dental, Dep25, DP, FP

Gold-G4, ST, INN, Pediatric Dental, Dep25, DP, FP

Platinum-P4, ST, INN, Pediatric Dental, Dep25, DP, FP

Individual Rate 1st Quarter* $543.25 $625.33 $733.06 $856.22 Individual Rate 2nd Quarter* $551.66 $635.01 $744.40 $869.47 Individual Rate 3rd Quarter* $560.20 $644.84 $755.92 $882.92 Individual Rate 4th Quarter* $568.87 $654.82 $767.62 $896.58 Deductible – Individual $4,425 $1,300 $600 $0Deductible – Family $8,850 $2,600 $1,200 $0MOOP – Individual $8,150 $7,900 $4,000 $2,000MOOP – Family $16,300 $15,800 $8,000 $4,000PCP 50% cost sharing $30 copay $25 copay $15 copaySpecialist 50% cost sharing $50 copay $40 copay $35 copayUrgent Care 50% cost sharing $70 copay $60 copay $55 copayAdult Dental / Vision Not covered Not covered Not covered Not coveredPrescription Drugs 30 Days $10/$35/$70 $10/$35/$70 $10/$35/$70 $10/$30/$60Mail Order Rx – 90 days $25/$87.50/$175 $25/$87.50/$175 $25/$87.50/$175 $25/$75/$150

Lab Work 50% cost sharing

Diagnostics(x-ray & blood work)

$50 per visit

Diagnostics(x-ray & blood work)

$40 per visit

Diagnostics(x-ray & blood work)

$35 per visitImaging (MRI, PET, CT)

$50 per visitImaging (MRI, PET, CT)

$40 per visitImaging (MRI, PET, CT)

$35 per visitInpatient (ER/Hospital) 50% cost sharing $250/$1500 $150/$1000 $100/$500Outpatient Surgery (Facility/Physician) 50% cost sharing $150 $100 $100

Exercise Facility Reimbursement

$200 per 6 month period

$200 per 6 month period

$200 per 6 month period

$200 per 6 month period

Pediatric Dental 50% cost sharing $30 copay $25 copay $15 copay

Pediatric Vision 50% cost sharingEye Exam – $30 copay

Glasses – 30% coinsurance

Eye Exam – $25 copayGlasses –

20% coinsurance

Eye Exam – $15 copayGlasses –

10% coinsurance

Other Services Chiropractic & Hearing Aids (50%)

Chiropractic ($50) & Hearing Aids (30%)

Chiropractic ($40) & Hearing Aids (20%)

Chiropractic ($35) & Hearing Aids (10%)

SMALL BUSINESS HEALTH OPTIONS PROGRAM (SHOP)

MetroPlus small business Plans at‑a‑glance 2020

* Multiply individual rate above by 2.00 for Employee + Spouse; by 1.70 for Employee + Child(ren); by 2.85 for Family MBR 19.227

See back for abbreviations/definitions.

nystateofhealth.ny.gov1.855.355.5777TTY: 1.800.662.1220

MetroPlus does not discriminate on the basis of race, color, national origin, sex, age, or disability

in its health programs and activities.

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Rider Definition

ST Standard Plan – Plan was designed by NY State of Health

INN In-Network Coverage Only

Pediatric Dental Pediatric Dental coverage for children age 18 or younger

Dep 25 Dependent coverage through age 25

DP Domestic partners are eligible for coverage

FP Family planning benefit is covered

nystateofhealth.ny.gov1.855.355.5777TTY: 1.800.662.1220