Aetna Health Inc. (a PA corp.) health insurance plan with the Plan ID 99129IL0120002. The plan is called Bronze: Aetna network of doctors & hospitals + Low-cost MinuteClinic + $0 Telehealth 24/7.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.14% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.86% of the costs of all covered benefits (according to the Issuer).
Health Insurance Plan ID | 99129IL0120002 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Illinois | ||||||||||||||||||
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 | 99129IL0120002-03 | ||||||||||||||||||
Provider Network(s) | ['ILN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 99129IL0120002-00 Standard On Exchange Plan - 99129IL0120002-01 |
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Last Plan Update Date | Fri, 16 Sep 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
Abortions are only covered when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest |
YES | 50.00% Coinsurance after deductible |
100.00% |
Accidental Dental
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Acupuncture
Limit: 10.0 Visit(s) per Year Exclusions: Coverage is limited to 10 visits per calendar year. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Allergy Testing
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Autism Spectrum Disorders
Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Bariatric Surgery
Pre-certification is required. Surgery for obesity will be a Covered Service only when required due to morbid obesity. The participant meets the current NIH (National Institutes of Health) surgical criteria. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Bones/Joints
Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Breast Implant Removal
Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Chemotherapy
Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
Limit: 25.0 Visit(s) per Year Benefits will be provided for manipulation or adjustment of osseous or articular structures, commonly referred to as chiropractic and osteopathic manipulation, when performed by a person licensed to perform such procedures. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Clinical Trials
Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Dental Anesthesia
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Care Management
Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Diabetes Education
Services must be rendered by a physician, or duly certified, registered or licensed health care professional with expertise in diabetes management. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Dialysis
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
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 year. Age 0-19. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Habilitation Services
Treatment must be medically necessary and therapeutic and not investigational. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Hearing Aids
Limit: 2.0 Item(s) per 2 Years Exclusions: Hearing aids limited to 1 hearing aid per ear every 24 months. Bone anchored hearing aids and cochlear implants are covered. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Home Health Care Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Hospice Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
Exclusions: Limited to 4 attempts, if live birth, 2 additional attempts covered. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Infusion Therapy
Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Inherited Metabolic Disorder - PKU
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | 50.00% Coinsurance 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
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Multiple Sclerosis
Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Non-Preferred Brand Drugs
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Nutritional Counseling
|
YES | No Charge |
100.00% |
Organ Transplants
Member cost share based on place and type of service. Network benefits must be received within the transplant network. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Prenatal and Postnatal Care
Member cost sharing applies to postnatal care |
YES | 50.00% Coinsurance after deductible |
100.00% |
Prescription Drugs Other
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 50.00% Coinsurance after deductible |
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 | 50.00% Coinsurance after deductible |
100.00% |
Private-Duty Nursing
Exclusions: Inpatient Private Duty Nursing Services are not covered. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Prosthetic Devices
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Provided when rendered by a registered Occupational Therapist or registered professional Physical Therapist under the supervision of a Physician. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Rehabilitative Speech Therapy
Provided when rendered by a licensed Speech Therapist or Speech Therapist certified by the American Speech and Hearing Association. |
YES | 50.00% Coinsurance 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 Year Exclusions: Coverage is limited to 1 exam every 12 months age 0-19. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Routine Foot Care
Only covered for persons diagnosed with diabetes. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Skilled Nursing Facility
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Specialty Drugs
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Transplant
Member cost share based on place and type of service. Network benefits must be received within the transplant network. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Weight Loss Programs
Online weight loss programs are available. |
NO | ||
Well Baby Visits and Care
Exclusions: Children immunizations covered at 100% deductible waived for children up to 72 months of age. Coverage is limited to 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 | 50.00% Coinsurance after deductible |
100.00% |
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 | 2023 |
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 |
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 | 0.9998 |
First Tier Utilization | 100% |
Formulary ID | ILF029 |
Formulary URL | URL |
HIOS Product ID | 99129IL012 |
Import Date | 9/16/2022 20:01 |
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? | Yes |
Issuer Actuarial Value | 64.14% |
Issuer ID | 99129 |
Issuer Marketplace Marketing Name | Aetna CVS Health |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Expanded Bronze |
Multiple In Network Tiers | No |
National Network | No |
Network ID | ILN001 |
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 | 1/1/2023 |
Plan ID (Standard Component ID with Variant) | 99129IL0120002-03 |
Plan Marketing Name | Bronze: Aetna network of doctors & hospitals + Low-cost MinuteClinic + $0 Telehealth 24/7 |
Plan Type | HMO |
Plan Variant Marketing Name | Bronze: Aetna network of doctors & hospitals + Low-cost MinuteClinic + $0 Telehealth 24/7 |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $1,100 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $6,000 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $0 |
SBC Scenario, Having Diabetes, Deductible | $5,400 |
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 | $2,800 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | ILS001 |
Source Name | SERFF |
Specialist Requiring a Referral | Referral required for all physicians EXCEPT PCP, OB/GYN, Pediatrician and MH/SUD providers. |
Plan ID | 99129IL0120002 |
State Code | IL |
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 | 50.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $12000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,000 |
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 | $14200 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7100 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,100 |
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 |
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, 20 Aug 2024 06:14 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