HealthKeepers, Inc. health insurance plan with the Plan ID 88380VA0720035. The plan is called Anthem HealthKeepers Silver X 2400 .
Based on the data of Health Plan Issuer, this plan has an actuarial value of 100.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 88380VA0720035 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Virginia | ||||||||||||||||||
Health Insurance Issuer | HealthKeepers, Inc. | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 88380VA0720035-02 | ||||||||||||||||||
Provider Network(s) | ['VAN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 01 Oct 2024 06:11 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 88380VA0720035-00 Standard On Exchange Plan - 88380VA0720035-01 Open to Indians below 300% FPL - 88380VA0720035-02 Open to Indians above 300% FPL - 88380VA0720035-03 73% AV Silver Plan - 88380VA0720035-04 |
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Last Plan Update Date | Wed, 25 Jan 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 01 Oct 2024 06:11 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
Treatment must begin within 12 months of the injury, or as soon after that as possible, to be covered. Cost-Share(s) determined based on type of service and place of service rendered. |
YES | 0.00% |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | 0.00% |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
YES | 0.00% |
100.00% |
Chemotherapy
In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Chiropractic Care
Limit: 30.0 Visit(s) per Benefit Period Rehabilitative Chiropractic care / spinal manipulation is limited to 30 visits per benefit period. Habilitative Chiropractic care / spinal manipulation is limited to 30 visits per year. Habilitation service limits are not combined with Rehabilitative service limits. |
YES | 0.00% |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
This benefit is for the hospital stay. In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year Limited to 2 visits per year. |
YES | $0.00 |
100.00% |
Diabetes Education
Cost-Share(s) determined based on type of service and place of service rendered. |
YES | 0.00% |
100.00% |
Dialysis
In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Durable Medical Equipment
Coverage for ongoing rental of equipment may be limited to the cost of purchasing the equipment. |
YES | 0.00% |
100.00% |
Emergency Room Services
|
YES | 0.00% |
0.00% |
Emergency Transportation/Ambulance
Benefits for Non-Emergency ambulance services when services have been pre-authorized by Anthem will be limited to $50,000 per occurrence if a Non-Network Provider is used. Includes medically necessary transportation to the nearest appropriate hospital for a medical emergency, or between hospitals or other approved facilities. Includes ground, water, fixed wing and rotary air transportation. Benefits also include medically necessary treatment of a sickness or injury by medical professionals from an ambulance service, even if you are not taken to a facility. Benefits are only available for air ambulance when it is not appropriate to use a ground or water ambulance. |
YES | 0.00% |
0.00% |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year Includes a choice of eyeglasses lenses or contact lenses within a benefit period. Covered eyeglasses lenses include standard plastic lenses in: Single vision, Bifocal, Trifocal, and Standard Progressive. Members choose from a limited frame selection. Coverage for contact lenses includes elective or non-elective contact lenses. Non-elective contact lenses are covered only for certain medical conditions. Limited to 1 item per year. |
YES | $0.00 |
100.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies. |
YES | $0.00 |
100.00% |
Habilitation Services
Habilitation Speech Therapy limited to 30 visits per year. Habilitation Physical therapy and Occupational therapy have a combined limit of 30 visits per benefit period. Habilitation service limits are not combined with Rehabilitative service limits. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Hearing Aids
|
NO | ||
Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period The Home Care visit limit will apply instead of the Therapy Services limits for physical, occupational, speech therapy, or cardiac rehabilitation for therapy in the home. Visit limit does not apply to home infusion therapy or home dialysis. Limited to 100 visits per benefit period. |
YES | 0.00% |
100.00% |
Hospice Services
|
YES | 0.00% |
100.00% |
Imaging (CT/PET Scans, MRIs)
In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 0.00% |
100.00% |
Laboratory Outpatient and Professional Services
In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
YES | 0.00% |
100.00% |
Mental/Behavioral Health Inpatient Services
In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Mental/Behavioral Health Outpatient Services
|
YES | 0.00% |
100.00% |
Non-Preferred Brand Drugs
30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies. |
YES | 0.00% |
100.00% |
Nutritional Counseling
|
YES | 0.00% |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Orthodontic Fixed Appliance Therapy, which is treatment that uses an appliance that is cemented or bonded to the teeth, is covered only once per lifetime for Dentally Necessary Coverage only. |
YES | 0.00% |
100.00% |
Other Practitioner Office Visit (Nurse, Physician Assistant)
You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our mobile application, website, or HealthKeepers enabled device. |
YES | $0.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period Rehabilitation Speech therapy limited to 30 visits per year. Rehabilitative Physical therapy and Occupational therapy have a combined limit of 30 visits per benefit period. Rehabilitative service limits are not combined with Habilitation service limits. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 0.00% |
100.00% |
Preferred Brand Drugs
30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies. |
YES | $0.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | 0.00% |
100.00% |
Preventive Care/Screening/Immunization
You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. |
YES | $0.00 |
100.00% |
Primary Care Visit to Treat an Injury or Illness
Copay is for office visit only, other services provided during the visit are subject to additional cost shares. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our mobile application, website, or HealthKeepers enabled device. Doctor Visits in the Home are covered. |
YES | $0.00 |
100.00% |
Private-Duty Nursing
Limit: 16.0 Hours per Benefit Period Private-Duty nursing in a home setting only. Limited to 16 hours per benefit period. |
YES | 0.00% |
100.00% |
Prosthetic Devices
The coinsurance for prosthetics for limb replacement can be no greater than 30%. Per the mandate "Limb" means an arm, a hand, a leg, a foot, or any portion of an arm, a hand, a leg, or a foot. All other prosthetic services are covered under the plan's base coinsurance (Coinsurance formula: If plan coinsurance is greater than 30% then coinsurance for Prosthetics for Limb Replacement is 30%. If plan coinsurance is equal to or less than 30% then coinsurance for Prosthetics for Limb Replacement, should be the plan coinsurance). |
YES | 0.00% |
100.00% |
Radiation
In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Reconstructive Surgery
|
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period Rehabilitation Physical therapy and Occupational therapy limited to 30 visits per benefit period combined. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. Rehabilitative service limits are not combined with Habilitation service limits. In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | 0.00% |
100.00% |
Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period Rehabilitation Speech therapy limited to 30 visits per benefit period. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. Rehabilitative service limits are not combined with Habilitation service limits. In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | 0.00% |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Benefit Period Includes complete eye exam with dilation, as needed to check all aspects of vision, including the structure of the eyes. Limited to 1 visit per year. |
YES | $0.00 |
100.00% |
Routine Foot Care
|
NO | ||
Skilled Nursing Facility
Limit: 100.0 Days per Stay In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. Limited to 100 days per stay. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Specialist Visit
Specialists Visits, Mental Health and Substance Use Office Visits apply deductible/coinsurance. Copays do not apply to these services. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our mobile application, website, or HealthKeepers enabled device. |
YES | 0.00% |
100.00% |
Specialty Drugs
30 day supply. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies. |
YES | 0.00% |
100.00% |
Substance Abuse Disorder Inpatient Services
In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | 0.00% |
100.00% |
Transplant
Unrelated Donor Search limited to a maximum of the 10 best matched donors, identified by an authorized registry. Medically Necessary charges for the procurement of an organ from a live donor are covered up to the maximum allowed amount, including complications from the donor procedure for up to six weeks from the date of procurement. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Urgent Care Centers or Facilities
|
YES | $0.00 |
$0.00 |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | $0.00 |
100.00% |
X-rays and Diagnostic Imaging
In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 1 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Zero Cost Sharing Plan Variation |
Dental Only Plan | No |
Design Type | Not Applicable |
Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 70% |
Formulary ID | VAF013 |
Formulary URL | URL |
HIOS Product ID | 88380VA072 |
Import Date | 1/25/2023 20:01 |
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 Actuarial Value | 100.00% |
Issuer ID | 88380 |
Issuer Marketplace Marketing Name | HealthKeepers, Inc. |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Silver |
Multiple In Network Tiers | Yes |
National Network | No |
Network ID | VAN001 |
Out of Country Coverage | No |
Out of Country Coverage Description | Urgent/Emergency Coverage Only |
Out of Service Area Coverage | No |
Out of Service Area Coverage Description | TRAD/PAR network |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 88380VA0720035-02 |
Plan Marketing Name | Anthem HealthKeepers Silver X 2400 |
Plan Type | HMO |
Plan Variant Marketing Name | Anthem HealthKeepers Silver X 2400 AI |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $0 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $0 |
SBC Scenario, Having Diabetes, Deductible | $0 |
SBC Scenario, Having Diabetes, Limit | $20 |
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 | $0 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Second Tier Utilization | 30% |
Service Area ID | VAS003 |
Source Name | SERFF |
Plan ID | 88380VA0720035 |
State Code | VA |
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 | $0 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 0.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
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 | $0 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $0 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $0 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $0 |
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 | Yes |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 01 Oct 2024 06:11 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