AmeriHealth Caritas Next Bronze Essential + No Referrals - 72760DE0010001 Health Insurance Plan
AmeriHealth Caritas VIP Next, Inc. health insurance plan with the Plan ID 72760DE0010001. The plan is called AmeriHealth Caritas Next Bronze Essential + No Referrals.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 59.65% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 40.35% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 72760DE0010001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Delaware | ||||||||||||||||||
| Health Insurance Issuer | AmeriHealth Caritas VIP Next, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 72760DE0010001-03 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 72760DE0010001-00 Standard On Exchange Plan - 72760DE0010001-01 |
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| Last Plan Update Date | Wed, 09 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of AmeriHealth Caritas Next Bronze Essential + No Referrals Health Insurance Plan, 72760DE0010001-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
100.00% |
| Autism Spectrum Disorders
|
YES | No Charge after deductible |
100.00% |
| Bariatric Surgery
|
YES | No Charge after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Cancer Monitoring Test
|
YES | No Charge after deductible |
100.00% |
| Cardiac Rehabilitation
Limit: 30.0 Visit(s) per Benefit Period Limited to 30 visits per benefit period. More available beyond the initial allotment if deemed medically necessary. |
YES | No Charge after deductible |
100.00% |
| Chemotherapy
|
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
The following limits apply: three modalities per visit, one visit per day. |
YES | No Charge after deductible |
100.00% |
| Clinical Trials
|
YES | No Charge after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Dental Services for Children with Severe Disabilities
|
YES | No Charge after deductible |
100.00% |
| Diabetes Care Management
|
YES | No Charge after deductible |
100.00% |
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
|
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
We cover ambulance services (including voluntary services) by ground, air, or water in the event of an emergency. Services must be provided by a licensed ambulance, including volunteer, service provider and must take you to the nearest hospital where emergency care can be provided. Air Ambulance is covered only when no other means of travel is appropriate. We also cover nonemergency ambulance transportation by a licensed ambulance service (either ground, air, or water ambulance) when the transport is: from an acute facility to a subacute facility/setting, from an out-of-network hospital/facility to an in-network hospital/facility, to a hospital that provides a higher level of care than was available at the original hospital/facility, or to a more cost-effective acute care facility. |
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | No Charge after deductible |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
|
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: Speech therapy is not covered for attention disorders, behavior problems, conceptual handicaps, learning disabilities, developmental delays. Combined limit of 30 visits per benefit period for Habilitative Physical Therapy and Occupational Therapy; 30 visits per benefit period for Habilitative Speech Therapy. Applied Behavior analysis for autism spectrum disorder is also covered,. |
YES | No Charge after deductible |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Benefits are limited to one wearable hearing aid per ear every three (3) years for children less than 24 years of age. |
YES | No Charge after deductible |
100.00% |
| Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period Exclusions: Chronic condition care is not covered; drugs; lab tests; imaging services; inhalation therapy; chemotherapy and radiation therapy; dietary care; durable medical equipment; disposable supplies; care not prescribed in the approved treatment plan; volunteer care. We will cover certain services received in the home from a certified/licensed home health agency when ordered by a physician. Examples of these services include skilled care, physical/ occupational/speech and language/respiratory therapy, social work services, and home infusion. Services must only be provided on a part-time, intermittent basis and cannot be solely for assisting with activities of daily living. There's a limit of one visit per day per specialty. (A nurse and home health aide count as one specialty for this benefit.) |
YES | No Charge after deductible |
100.00% |
| Hospice Services
Exclusions: Private duty nursing; respite care; care not prescribed in the approved treatment plan; financial, legal, or estate planning, and; hospice care in an acute care facility, except when a patient in hospice care requires services in an inpatient setting for a limited time |
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
Limit: 6.0 Procedure(s) per Lifetime Exclusions: For IVF services, retrievals must be completed before the individual is 45 years old and transfers must be completed before the individual is 50 years old. The benefit is limited to six (6) completed egg retrievals per lifetime, with unlimited embryo transfers in accordance with the guidelines of the American Society for Reproductive Medicine, using single embryo transfer (SET) when recommended and medically appropriate. We will cover services for the diagnosis, treatment, and correction of any underlying causes of infertility when determined to be medically necessary by a network provider. This includes coverage of certain prescription drugs, in vitro fertilization (IVF), Gamete Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer (ZIFT), and standard fertility preservation services for covered persons who must undergo medically necessary treatment that may cause iatrogenic infertility. |
YES | No Charge after deductible |
100.00% |
| Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
| Inherited Metabolic Disorder - PKU
|
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: Exclusions include certain mental health and substance abuse services, including: aptitude tests, testing and treatment for learning disabilities, treatment for personality disorders, treatment [of] factitious disorders, treatment of sleep disorders, treatment of sexual and gender identity disorders, care beyond that needed to determine mental deficiency or retardation, marital/relationship counseling, and care at behavioral health facilities. Methadone is not Covered |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: Exclusions include certain mental health and substance abuse services, including: aptitude tests, testing and treatment for learning disabilities, treatment for personality disorders, treatment [of] factitious disorders, treatment of sleep disorders, treatment of sexual and gender identity disorders, care beyond that needed to determine mental deficiency or retardation, marital/relationship counseling, and care at behavioral health facilities. Psychological tests (limit of 8 hours of tests per year). Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. |
YES | No Charge after deductible |
100.00% |
| Newborn Hearing Screening
|
YES | No Charge |
100.00% |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
Also covered per USPSTF guidelines. |
YES | No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: OT and PT covered only when needed to help your condition improve in a reasonable and predictable time. Combined limit of 30 visits per benefit period for Rehabilitative Physical Therapy and Occupational Therapy; 30 visits per benefit period for Rehabilitative Speech Therapy. |
YES | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Colorectal cancer screening must be covered. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits |
YES | No Charge after deductible |
100.00% |
| Private-Duty Nursing
Limit: 240.0 Hours per Benefit Period Exclusions: This care isn't covered when done in special care units of the hospital, such as: self-care units; selective care units; intensive care units. Covered health services under this section include medically necessary nursing care provided to a patient one on one by licensed nurses in an inpatient or home setting. Private duty nursing care is covered when you are an inpatient in an acute hospital. This care isn't covered when done in special care units of the hospital such as: self-care units, selective care units, and intensive care units. Inpatient private duty nursing care is not covered when done as a convenience even if authorized by your doctor. |
YES | No Charge after deductible |
100.00% |
| Prosthetic Devices
|
YES | No Charge after deductible |
100.00% |
| Pulmonary Rehabilitation
Limit: 36.0 Treatment(s) per Benefit Period Limited to 2 - 1 hour treatments per day, up to 36 treatments within a benefit period. More available beyond the initial allotment if deemed medically necessary. |
YES | No Charge after deductible |
100.00% |
| Radiation
Radiation therapy is covered for cancer and neoplastic diseases. |
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
Only for breast reconstruction. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period Exclusions: OT and PT covered only when needed to help your condition improve in a reasonable and predictable time. Combined limit of 30 visits per benefit period for Rehabilitative Physical Therapy and Occupational Therapy. Must be needed to help your condition improve in a reasonable and predictable time, or needed to establish an effective home exercise program. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period Exclusions: Speech therapy is not covered for attention disorders, behavior problems, conceptual handicaps, learning disabilities, developmental delays. Combined Rehabilitative and Habilitative limit of 30 visits per benefit period. Must be needed to improve speech problems caused by disease, trauma, congenital defect, or recent surgery. |
YES | No Charge after deductible |
100.00% |
| Reversible Contraceptives
|
YES | No Charge after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period |
YES | No Charge after deductible |
100.00% |
| Routine Foot Care
|
YES | No Charge after deductible |
100.00% |
| School Based Health Centers
|
YES | No Charge after deductible |
100.00% |
| Skilled Nursing Facility
Limit: 120.0 Days per Admission Exclusions: Covered health services do not include custodial, domiciliary care, or long-term care admissions. The skilled nursing facility is a Network Provider. Coverage is limited to 120 days per confinement. A confinement includes all admissions not separated by 180 days. |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
Dermatology virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits |
YES | No Charge after deductible |
100.00% |
| Specialty Drugs
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. |
YES | No Charge after deductible |
100.00% |
| Transplant
Your health benefit plan has a maximum benefit limit per transplant of $10,000 for each cadaveric organ and up to $45,000 for each organ procured from a living donor including organ harvesting. Kidney and bone marrow transplants do not apply to this limit. For kidney transplants, if there is not a network transplant facility available living donor costs are limited to $50,000 not including harvesting. |
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Treatment is covered if there is documented organic joint disease, or joint damage resulting from physical trauma |
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits |
YES | No Charge after deductible |
No Charge after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
100.00% |
AmeriHealth Caritas Next Bronze Essential + No Referrals Health Insurance Plan Variant 72760DE0010001-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.5965205611925151 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | DEF001 |
| Formulary URL | URL |
| HIOS Product ID | 72760DE001 |
| Import Date | 2024-10-09 20:01:46 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 72760 |
| Issuer Marketplace Marketing Name | AmeriHealth Caritas Next |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | DEN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Accidental Injury and Emergency Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Accidental Injury and Emergency Only |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 72760DE0010001-03 |
| Plan Marketing Name | AmeriHealth Caritas Next Bronze Essential + No Referrals |
| Plan Type | HMO |
| Plan Variant Marketing Name | AmeriHealth Caritas Next Bronze Essential + No Referrals |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $9,200 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,300 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | DES001 |
| Source Name | SERFF |
| Plan ID | 72760DE0010001 |
| State Code | DE |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $18400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $9200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $9,200 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of AmeriHealth Caritas Next Bronze Essential + No Referrals Health Insurance Plan, 72760DE0010001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about AmeriHealth Caritas Next Bronze Essential + No Referrals, 72760DE0010001 Health Insurance Plan, 72760DE0010001
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Does AmeriHealth Caritas Next Bronze Essential + No Referrals Health Insurance Plan, 72760DE0010001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (72760DE0010001) Health Insurance Plan, Variant (72760DE0010001-03) have Out Of Country Coverage?
Does (72760DE0010001) Health Insurance Plan, Variant (72760DE0010001-03) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API