Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 - 96992IN0060002 Health Insurance Plan
Aetna Health Inc. (a PA corp.) health insurance plan with the Plan ID 96992IN0060002. The plan is called Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.98% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.02% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 96992IN0060002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Indiana | ||||||||||||||||||
| Health Insurance Issuer | Aetna Health Inc. (a PA corp.) | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 96992IN0060002-01 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED 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 - 96992IN0060002-00 Standard On Exchange Plan - 96992IN0060002-01 |
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| Last Plan Update Date | Thu, 26 Oct 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 96992IN0060002-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Per Indiana law, abortion only covered if performed because a woman becomes pregnant through an act of rape or incest; or an abortion is necessary to avert the pregnant woman?s death or a substantial and irreversible impairment of a major bodily function of the pregnant woman |
NO | ||
| Accidental Dental
Exclusions: Member cost share based on place and type of service. |
YES | $100.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Exclusions: Member cost share based on place and type of service. Cost share driven by provider/setting. |
YES | $100.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Exclusions: Member cost share based on place and type of service. Cost share driven by provider/setting. |
YES | $750.00 |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Benefit Period Exclusions: Coverage limited to 12 visits per calendar year. Limit combined In and out of network. Cost share driven by provider/setting. |
YES | $15.00 |
100.00% |
| Clinical Trials
Exclusions: Member cost share based on place and type of service. |
YES | $100.00 |
100.00% |
| Cosmetic Surgery
Exclusions: Covered for reconstructive surgery. Copay per day for days 1-3 |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Copay per day for days 1-3 |
YES | $2,500.00 |
100.00% |
| Dental Anesthesia
|
YES | 50.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
Exclusions: Member cost share based on place and type of service. |
YES | $100.00 |
100.00% |
| Diabetes Education
Exclusions: Member cost share based on place and type of service. |
YES | $100.00 |
100.00% |
| Dialysis
Exclusions: Member cost share based on place and type of service. |
YES | $1,000.00 |
100.00% |
| Durable Medical Equipment
One wig per benefit period combined both In and Out of Network. Network and Non-Network for wigs following cancer treatment. |
YES | 50.00% |
100.00% |
| Emergency Room Services
Exclusions: No coverage for non-emergency use of the emergency room. |
YES | $2,200.00 |
$2,200.00 |
| Emergency Transportation/Ambulance
|
YES | $2,200.00 |
$2,200.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per calendar year, age 0-19. |
YES | $10.00 |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. No Copayment /Coinsurance will apply to orally administered cancer chemotherapy when obtained from a Network Pharmacy, Mail Service Program, or Specialty Pharmacy Network. |
YES | $40.00 |
100.00% |
| Habilitation Services
Cost share is driven by provider/setting. |
YES | $100.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period Exclusions: Coverage limited to 100 visits per calendar year. Combined In and out of network. Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home. |
YES | $80.00 |
100.00% |
| Hospice Services
Exclusions: Member cost share based on place and type of service. Copay per day for days 1-3 |
YES | $2,500.00 |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $750.00 |
100.00% |
| Infertility Treatment
Exclusions: Coverage limited to diagnosis and treatment of the underlying medical condition. Member cost share based on place and type of service. |
NO | ||
| Infusion Therapy
Exclusions: Member cost share based on place and type of service. Cost share driven by provider/setting. |
YES | $750.00 |
100.00% |
| Inherited Metabolic Disorder - PKU
Exclusions: Covers nutritional supplements, metabolic disorders, and medical products. Applicable medical or prescription drug cost share may apply. |
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network.Copay per day for days 1-3 |
YES | $2500.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $50.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Copay per day for days 1-3 |
YES | $2500.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost share driven by provider/setting. |
YES | $15.00 |
100.00% |
| Mental Health Other
Exclusions: Member cost share based on place and type of service. |
YES | $15.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. No Copayment /Coinsurance will apply to orally administered cancer chemotherapy when obtained from a Network Pharmacy, Mail Service Program, or Specialty Pharmacy Network. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Cost share driven by provider/setting. |
YES | No Charge |
100.00% |
| Off Label Prescription Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $15.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $1,000.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Benefit Period Exclusions: Coverage is limited to 20 visits each for PT/OT/ST per calendar year, rehabilitation & habilitation separate. Cost share is driven by provider/setting. Coverage for Speech Therapy is limited to 20 visits per benefit period, Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to 20 visits per benefit period. These limits are combined in and out of network. Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network. Cardiac Rehabilitation limited to 36 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non- Network when rendered in the home, Home Care Services limits apply. Pulmonary Rehabilitation limited to 20 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non- Network. When rendered in the home, Home Care Services limits apply. When rendered as part of physical therapy, the Physical Therapy limit will apply instead of the limit indicated. |
YES | $80.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $500.00 |
100.00% |
| Preferred Brand Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. No Copayment /Coinsurance will apply to orally administered cancer chemotherapy when obtained from a Network Pharmacy, Mail Service Program, or Specialty Pharmacy Network. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Prenatal and Postnatal Care
Exclusions: Member cost sharing applies to postnatal care |
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: Age and frequency schedules may apply. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $15.00 |
100.00% |
| Private-Duty Nursing
Limit: 82.0 Visit(s) per Year Exclusions: Coverage is limited to 82 shifts per calendar year. |
YES | 50.00% |
100.00% |
| Prosthetic Devices
Must be medically necessary. |
YES | 50.00% |
100.00% |
| Radiation
Exclusions: Member cost share based on place and type of service. Cost share driven by provider/setting. |
YES | 50.00% |
100.00% |
| Reconstructive Surgery
Exclusions: Member cost share based on place and type of service.Excludes all other reconstructive services that are not specifically outlined in Covered Services. Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed. Reconstructive services required due to prior therapeutic process are payable only if the original procedure would have been a covered service under this plan.Copay per day for days 1-3 |
YES | $2,500.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Benefit Period Exclusions: Coverage is limited to 20 visits PT and 20 visits OT per calendar year, rehabilitation & habilitation separate. Cost share is driven by provider/setting. Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period. Both apply to In-Network Providers and Non-Network Providers combined. Coverage also includes an additional 20 visits each for habilitative services. |
YES | $80.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period Exclusions: Coverage is limited to 20 visits per calendar year, rehabilitation & habilitation separate. Combined In and out of network. Cost share driven by provider/setting. |
YES | $80.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Exclusions: Coverage is limited to 1 exam per calendar year, age 0-19. |
YES | $10.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 90.0 Days per Benefit Period Exclusions: Coverage limited to 90 days per calendar year. Limit is combined both In and Out of Network.Copay per day for days 1-3 |
YES | $2500.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $100.00 |
100.00% |
| Specialty Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. No Copayment /Coinsurance will apply to orally administered cancer chemotherapy when obtained from a Network Pharmacy, Mail Service Program, or Specialty Pharmacy Network. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Copay per day for days 1-3 |
YES | $2500.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
Cost share driven by provider/setting. |
YES | $15.00 |
100.00% |
| Transplant
Exclusions: Member cost share based on place and type of service. Network benefits must be received within the transplant network. Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined).Copay per day for days 1-3 |
YES | $2,500.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: Coverage includes diagnostic and surgical treatment of TMJ . |
YES | $100.00 |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: No coverage for non-urgent care. |
YES | $50.00 |
100.00% |
| Weight Loss Programs
Exclusions: Online weight loss programs are available. |
NO | ||
| Well Baby Visits and Care
Exclusions: Age and frequency schedules may apply. Coverage is limited 7 exams in the first 12 months of life; 3 exams in the second 12 months of life; 3 exams in the third 12 months of life; 1 exam every 12 months thereafter to age 22. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $75.00 |
100.00% |
Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan Variant 96992IN0060002-01 Attributes
| Plan Attribute | Value |
|---|---|
| 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 | Standard Bronze On Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $8990 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4495 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $4,495 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| 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, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | INF017 |
| Formulary URL | URL |
| HIOS Product ID | 96992IN006 |
| Import Date | 2023-10-26 01:01:56 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | 0 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 64.98% |
| Issuer ID | 96992 |
| Issuer Marketplace Marketing Name | Aetna CVS Health |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | INN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Except for Emergencies |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 96992IN0060002-01 |
| Plan Marketing Name | Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $5,300 |
| 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 | $600 |
| SBC Scenario, Having Diabetes, Deductible | $3,100 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | INS001 |
| Source Name | HIOS |
| Plan ID | 96992IN0060002 |
| State Code | IN |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,400 |
| 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 | Yes |
Copay & Coinsurance of Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 96992IN0060002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7, 96992IN0060002 Health Insurance Plan, 96992IN0060002
-
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 96992IN0060002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (96992IN0060002) Health Insurance Plan, Variant (96992IN0060002-01) offer Disease Management Programs?
Does (96992IN0060002) Health Insurance Plan, Variant (96992IN0060002-01) have Out Of Country Coverage?
Does (96992IN0060002) Health Insurance Plan, Variant (96992IN0060002-01) have Out of Service Area Coverage?
Does (96992IN0060002) Health Insurance Plan, Variant (96992IN0060002-01) offer Disease Management Programs?
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (96992IN0060002-01) offer Disease Management Programs for Asthma?
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (96992IN0060002-01) offer Disease Management Programs for Heart disease?
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (96992IN0060002-01) offer Disease Management Programs for Depression?
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (96992IN0060002-01) offer Disease Management Programs for Diabetes?
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (96992IN0060002-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (96992IN0060002-01) offer Disease Management Programs for Low back pain?
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (96992IN0060002-01) 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