Ascension Personalized Care Low Premium Silver - 57125TX0090007 Health Insurance Plan
US Health and Life Insurance Company health insurance plan with the Plan ID 57125TX0090007. The plan is called Ascension Personalized Care Low Premium Silver.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.55% (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 5.45% 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 | 57125TX0090007 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | US Health and Life Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 57125TX0090007-06 | ||||||||||||||||||
| Provider Network(s) | ['TXN001'] | ||||||||||||||||||
| 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 - 57125TX0090007-00 Standard On Exchange Plan - 57125TX0090007-01 Open to Indians below 300% FPL - 57125TX0090007-02 Open to Indians above 300% FPL - 57125TX0090007-03 73% AV Silver Plan - 57125TX0090007-04 |
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| Last Plan Update Date | Tue, 05 Mar 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Ascension Personalized Care Low Premium Silver Health Insurance Plan, 57125TX0090007-06
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 20.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 20.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 20.00% |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
YES | 20.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section. |
YES | 20.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 20.00% |
100.00% |
| Dialysis
|
YES | 20.00% |
100.00% |
| Durable Medical Equipment
|
YES | 20.00% |
100.00% |
| Emergency Room Services
|
YES | 20.00% |
20.00% |
| Emergency Transportation/Ambulance
|
YES | 20.00% |
20.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 20.00% |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
|
YES | $10.00 |
100.00% |
| Habilitation Services
Limit: 35.0 Visit(s) per Year Habilitative and rehabilitative limits cannot be combined for plans issued or renewed on or after January 1, 2017. Habilitation services includes autism services, and the benchmark plan does not impose age or maximums on autism coverage. |
YES | 20.00% |
100.00% |
| Hearing Aids
To restore or correction of impaired speech or hearing loss. |
YES | 20.00% |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | 20.00% |
100.00% |
| Hospice Services
Preauthorization is required. |
YES | 20.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 20.00% |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 20.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required. |
YES | 20.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 20.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 20.00% |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Preauthorization is required. |
YES | 20.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
Preauthorization is required. |
YES | No Charge |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $10.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 20.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
YES | 20.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 20.00% |
100.00% |
| Preferred Brand Drugs
|
YES | $20.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | No Charge |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Medically necessary foot orthotics are not subject to a calendar year maximum. |
YES | 20.00% |
100.00% |
| Radiation
|
YES | 20.00% |
100.00% |
| Reconstructive Surgery
Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. |
YES | 20.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | 20.00% |
100.00% |
| Rehabilitative Speech Therapy
|
YES | 20.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 25.0 Visit(s) per Year |
YES | 20.00% |
100.00% |
| Specialist Visit
|
YES | $10.00 |
100.00% |
| Specialty Drugs
|
YES | 50.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
Preauthorization is required. |
YES | 20.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
Certain services require preauthorization. |
YES | No Charge |
100.00% |
| Transplant
Preauthorization is required. |
YES | 20.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Though state law only mandates coverage for temporomandibular joint (TMJ) disorders for large group plans and HMOs, the benchmark plan covers TMJ. Therefore, it is considered part of the EHB package for Texas. |
YES | 20.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | 50.00% |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 20.00% |
100.00% |
Ascension Personalized Care Low Premium Silver Health Insurance Plan Variant 57125TX0090007-06 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.945519887123444 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | 94% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | TXF007 |
| Formulary URL | URL |
| HIOS Product ID | 57125TX009 |
| Import Date | 2024-03-05 01:01:47 |
| 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 | 57125 |
| Issuer Marketplace Marketing Name | US Health and Life |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | TXN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 57125TX0090007-06 |
| Plan Marketing Name | Ascension Personalized Care Low Premium Silver |
| Plan Type | EPO |
| Plan Variant Marketing Name | Ascension Personalized Care Low Premium Silver |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,200 |
| 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 | $200 |
| SBC Scenario, Having Diabetes, Copayment | $400 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $40 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TXS001 |
| Source Name | HIOS |
| Plan ID | 57125TX0090007 |
| State Code | TX |
| 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 | 20.00% |
| 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, 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 | $2400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $1200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $1,200 |
| 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 | No |
Copay & Coinsurance of Ascension Personalized Care Low Premium Silver Health Insurance Plan, 57125TX0090007
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Ascension Personalized Care Low Premium Silver, 57125TX0090007 Health Insurance Plan, 57125TX0090007
-
Does Ascension Personalized Care Low Premium Silver Health Insurance Plan, 57125TX0090007 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (57125TX0090007) Health Insurance Plan, Variant (57125TX0090007-06) offer Disease Management Programs?
Does (57125TX0090007) Health Insurance Plan, Variant (57125TX0090007-06) have Out Of Country Coverage?
Does (57125TX0090007) Health Insurance Plan, Variant (57125TX0090007-06) have Out of Service Area Coverage?
Does (57125TX0090007) Health Insurance Plan, Variant (57125TX0090007-06) offer Disease Management Programs?
Does Ascension Personalized Care Low Premium Silver Health Insurance Plan, Variant (57125TX0090007-06) offer Disease Management Programs for Asthma?
Does Ascension Personalized Care Low Premium Silver Health Insurance Plan, Variant (57125TX0090007-06) offer Disease Management Programs for Heart disease?
Does Ascension Personalized Care Low Premium Silver Health Insurance Plan, Variant (57125TX0090007-06) offer Disease Management Programs for Depression?
Does Ascension Personalized Care Low Premium Silver Health Insurance Plan, Variant (57125TX0090007-06) offer Disease Management Programs for Diabetes?
Does Ascension Personalized Care Low Premium Silver Health Insurance Plan, Variant (57125TX0090007-06) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Ascension Personalized Care Low Premium Silver Health Insurance Plan, Variant (57125TX0090007-06) offer Disease Management Programs for Pregnancy?
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