CareSource Marketplace Essential Silver Dental, Vision, & Fitness - 54192IN0020021 Health Insurance Plan
CareSource Indiana, Inc. health insurance plan with the Plan ID 54192IN0020021. The plan is called CareSource Marketplace Essential Silver Dental, Vision, & Fitness.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.06% (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 29.94% 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 | 54192IN0020021 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Indiana | ||||||||||||||||||
| Health Insurance Issuer | CareSource Indiana, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 54192IN0020021-00 | ||||||||||||||||||
| 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 - 54192IN0020021-00 Standard On Exchange Plan - 54192IN0020021-01 Open to Indians below 300% FPL - 54192IN0020021-02 Open to Indians above 300% FPL - 54192IN0020021-03 73% AV Silver Plan - 54192IN0020021-04 |
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| Last Plan Update Date | Wed, 13 Sep 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of CareSource Marketplace Essential Silver Dental, Vision, & Fitness Health Insurance Plan, 54192IN0020021-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Limit: 3000.0 Dollars per Episode Injury as a result of chewing or biting is not considered an accidental injury. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits. |
YES | 25.00% |
100.00% |
| Basic Dental Care - Child
See plan documents for details on benefit limits |
YES | No Charge after deductible |
100.00% |
| Chemotherapy
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Year |
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
Limit: 2.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Diabetes Education
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
Ambulance transports must be made to the closest local facility that can provide you with covered services appropriate for your medical condition. |
YES | 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Limited to one pair of glasses or contact lenses per benefit year. |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
|
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year Physical Therapy, Occupational Therapy, and Speech Therapy limited to 20 visits each per benefit period. |
YES | No Charge after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period A visit equals at least 4 hours. Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 0.00% Coinsurance after deductible |
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). |
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
$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits. |
YES | 45.00% |
100.00% |
| Major Dental Care - Child
See plan documents for details on benefit limits |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
$0 for first three visits then No Charge after deductible |
YES | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Limited to Medically Necessary Orthodontia. See plan documents for details on benefit limits. |
YES | No Charge after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
$0 for first three visits then No Charge after deductible when categorized as a PCP |
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: 60.0 Visit(s) per Year Physical Therapy, Occupational Therapy, and Speech Therapy limited to 20 visits each per benefit period.? Cardiac Rehabilitation limited to 36 visits. |
YES | 0.00% Coinsurance 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 after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
$0 for first three visits then No Charge after deductible |
YES | No Charge after deductible |
100.00% |
| Private-Duty Nursing
Limit: 100.0 Visit(s) per Year A visit equals 8 hours. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year Physical Therapy and Occupational Therapy limited to 20 visits each per benefit period. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year $1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits. |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
Limit: 2.0 Visit(s) per Year |
YES | $50.00 |
100.00% |
| 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: 90.0 Days per Year |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
|
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
$0 for first three visits then No Charge after deductible |
YES | No Charge after deductible |
100.00% |
| Transplant
Quantitative limit units apply, see Summary of Benefits and Coverage. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
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% |
CareSource Marketplace Essential Silver Dental, Vision, & Fitness Health Insurance Plan Variant 54192IN0020021-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7005893330672701 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
| 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 Silver Off Exchange Plan |
| 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 | 0.9817599884441199 |
| First Tier Utilization | 100% |
| Formulary ID | INF011 |
| Formulary URL | URL |
| HIOS Product ID | 54192IN002 |
| Import Date | 2023-09-13 01:02:10 |
| 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 | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 54192 |
| Issuer Marketplace Marketing Name | CareSource |
| 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 | INN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services Only |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 54192IN0020021-00 |
| Plan Marketing Name | CareSource Marketplace Essential Silver Dental, Vision, & Fitness |
| Plan Type | HMO |
| Plan Variant Marketing Name | CareSource Marketplace Essential Silver Dental, Vision, & Fitness |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $6,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,200 |
| 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 | INS001 |
| Source Name | HIOS |
| Plan ID | 54192IN0020021 |
| State Code | IN |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $13000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $6500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $6,500 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $13000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $6500 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $6,500 |
| 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 | $13000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,500 |
| 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 | $13000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,500 |
| 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 CareSource Marketplace Essential Silver Dental, Vision, & Fitness Health Insurance Plan, 54192IN0020021
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about CareSource Marketplace Essential Silver Dental, Vision, & Fitness, 54192IN0020021 Health Insurance Plan, 54192IN0020021
-
Does CareSource Marketplace Essential Silver Dental, Vision, & Fitness Health Insurance Plan, 54192IN0020021 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (54192IN0020021) Health Insurance Plan, Variant (54192IN0020021-00) offer Disease Management Programs?
Does (54192IN0020021) Health Insurance Plan, Variant (54192IN0020021-00) have Out Of Country Coverage?
Does (54192IN0020021) Health Insurance Plan, Variant (54192IN0020021-00) have Out of Service Area Coverage?
Does (54192IN0020021) Health Insurance Plan, Variant (54192IN0020021-00) offer Disease Management Programs?
Does CareSource Marketplace Essential Silver Dental, Vision, & Fitness Health Insurance Plan, Variant (54192IN0020021-00) offer Disease Management Programs for Asthma?
Does CareSource Marketplace Essential Silver Dental, Vision, & Fitness Health Insurance Plan, Variant (54192IN0020021-00) offer Disease Management Programs for Heart disease?
Does CareSource Marketplace Essential Silver Dental, Vision, & Fitness Health Insurance Plan, Variant (54192IN0020021-00) offer Disease Management Programs for Depression?
Does CareSource Marketplace Essential Silver Dental, Vision, & Fitness Health Insurance Plan, Variant (54192IN0020021-00) offer Disease Management Programs for Diabetes?
Does CareSource Marketplace Essential Silver Dental, Vision, & Fitness Health Insurance Plan, Variant (54192IN0020021-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does CareSource Marketplace Essential Silver Dental, Vision, & Fitness Health Insurance Plan, Variant (54192IN0020021-00) offer Disease Management Programs for Low back pain?
Does CareSource Marketplace Essential Silver Dental, Vision, & Fitness Health Insurance Plan, Variant (54192IN0020021-00) 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