Core Care Bronze 1

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Benefits and Coverage (assuming you use preferred providers) (Note: For a more detailed and accurate explanation of the benefits offered by this plan please refer to the Summary of Benefits and Coverage [SBC]. The benefits are described in more detail in the SBC and it will include additional information about those benefits. Some nuances about the benefits like visit limits and other details are not listed below. You should refer to the SBC for those details about the plan. Click on the "View Summary of Benefits and Coverage" link above to view the SBC.)
Plan id	19722NM0010003-01
CSR Variation Type	Standard Bronze On Exchange Plan
Insurance Company	Molina Healthcare
Plan Type	HMO
Plan Metal Level	Bronze
Link to Plan's Doctor Directory	View Plan's Doctor Directory
List of Hospitals in Plan's Network	Show Hospitals
Summary of Benefits and Coverage	View Summary of Benefits and Coverage
Estimated Monthly Premium Savings (APTC)
Monthly Premium Cost after Subtracting the Estimated Subsidy (Subsidies are not available for Catastrophic Plans)
Cost in a Good Year: Estimated Yearly Cost to You if Your Health Care Usage is Low (for Very Healthy Consumers "Low" is Defined as Only Preventive Care)	Use 2021 New Mexico Plan Comparison Tool to find out.
Your Chances of Having a Good Year--a Year with No More Than Low-Usage
Cost in an Average Year: Average for People Like You
Cost in a Bad Year: Estimate for People Like You in a High-Health Care Usage Year
Your Chances of Having a Bad Year--a Year with Very High Usage
Actual Maximum Out-of-Pocket (includes premiums)
In-Network Deductible (Note: Unless excepted in the plan's benefit description, you must pay all the costs up to the deductible amount before the plan begins to pay for covered services you use. There may be additional details about the deductible that are not shown below. Please refer to the SBC for additional details.)	$6,100
Extra Deductible for Drugs
Doctor Visits
Doctor Visit - Preventive Care	No Charge
Doctor Visit - Primary Care	$35 Copay after deductible
Doctor Visit - Specialist	$75 Copay after deductible
Doctor Visit - Well Baby Visits and Care	No Charge
Other Practitioner Office Visit (Nurse, Physician Assistant)	$35 Copay after deductible
Hospital
Inpatient Hospital Facility	50% Coinsurance after deductible
Inpatient Hospital Physician/Surgeon	50% Coinsurance after deductible
Outpatient Hospital Facility	50% Coinsurance after deductible
Outpatient Hospital Physician/Surgeon	50% Coinsurance after deductible
Inpatient Maternity Services	50% Coinsurance after deductible
Emergency
Emergency Room Services	50% Coinsurance after deductible
Emergency Medical Transportation	50% Coinsurance after deductible
Urgent Care Centers or Facilities	$35 Copay after deductible
Drugs
Plan's Drug Formulary	View Plan's Drug Formulary
Generic Drug on Formulary in a Local Pharmacy	$27 Copay
Preferred Brand Drug on Formulary in a Local Pharmacy	50% Coinsurance after deductible
Non-Preferred Brand Drug on Formulary in a Local Pharmacy	50% Coinsurance after deductible
Specialty Drug on Formulary in a Local Pharmacy	50% Coinsurance after deductible
Tests & Imaging
Diagnostic Tests (Blood work)	50% Coinsurance after deductible
X-Rays	50% Coinsurance after deductible
Imaging (CT/PET Scans, MRI, etc)	50% Coinsurance after deductible
Mental/Behavioral Health
Mental/Behavioral Health Inpatient Services	50% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services	$35 Copay after deductible
Substance Use Disorder Inpatient	50% Coinsurance after deductible
Substance Use Disorder Outpatient	$35 Copay after deductible
Vision/Hearing Aids
Routine Eye Exam for Child	No Charge
Eye Glasses for Child	No Charge
Routine Eye Exam - Adult
Hearing Aids	50% Coinsurance after deductible
Child Dental Coverage
Dental Check-Up for Children
Basic Dental Care – Child
Major Dental Care – Child
Orthodontia – Child
Adult Dental Coverage
Basic Dental Care – Adult
Major Dental Care – Adult
Orthodontia – Adult
Accidental Dental	50% Coinsurance after deductible
Home and Nursing Care
Home Health Care Services	No Charge after deductible
Skilled Nursing Care - Facility	50% Coinsurance after deductible
Rehabilitative and habilitative services
Habilitation Services	$35 Copay after deductible
Outpatient Rehabilitation Services	$35 Copay after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	$35 Copay after deductible
Rehabilitative Speech Therapy	$35 Copay after deductible
Other Services
Is HSA Eligible?	No
Allergy Testing	$35 Copay after deductible
Chemotherapy	50% Coinsurance after deductible
Chiropractic	$35 Copay after deductible
Diabetes Education	No Charge
Dialysis	$75 Copay after deductible
Durable Medical Equipment	50% Coinsurance after deductible
Hospice Service	No Charge
Infusion Therapy
Nutritional Counseling	$35 Copay after deductible
Prosthetic Devices	50% Coinsurance after deductible
Radiation	50% Coinsurance after deductible
Reconstructive Surgery	50% Coinsurance after deductible
Routine Foot Care
Treatment for Temporomandibular Joint Disorders	50% Coinsurance after deductible
Transplant	50% Coinsurance after deductible
Weight Loss Programs
Wellness Programs
Asthma Program	Available
Heart Disease Program	Available
Depression Program	Available
Diabetes Program	Available
High Blood Pressure & Cholesterol Program	Available
Low Back Pain Program	Not Available
Pain Management Program	Not Available
Pregnancy Program	Not Available
Weight Loss Programs	Not Available
Out-of-Network - See Summary of Benefits and Coverage	View Summary of Benefits and Coverage