CareSource Indiana, Inc. health insurance plan with the Plan ID 54192IN0020020. The plan is called CareSource Marketplace Low Premium Bronze Dental, Vision, & Fitness.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 60.70% (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 39.30% 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 | 54192IN0020020 | ||||||||||||||||||
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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 | 54192IN0020020-01 | ||||||||||||||||||
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 - 54192IN0020020-00 Standard On Exchange Plan - 54192IN0020020-01 |
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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 |
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 | 40.00% |
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 | $25.00 |
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 | 50.00% |
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
|
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)
|
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 | 0.00% |
100.00% |
Primary Care Visit to Treat an Injury or Illness
|
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 | 40.00% |
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
|
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% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.607021482367151 |
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 |
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 | 0.9782479688477591 |
First Tier Utilization | 100% |
Formulary ID | INF008 |
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 | Bronze |
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) | 54192IN0020020-01 |
Plan Marketing Name | CareSource Marketplace Low Premium Bronze Dental, Vision, & Fitness |
Plan Type | HMO |
Plan Variant Marketing Name | CareSource Marketplace Low Premium Bronze 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 | $9,450 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $100 |
SBC Scenario, Having Diabetes, Deductible | $5,100 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $10 |
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 | 54192IN0020020 |
State Code | IN |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $18900 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $9450 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $9,450 |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $18900 per group |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $9450 per person |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $9,450 |
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 | $18900 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $9450 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $9,450 |
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 | $18900 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9450 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,450 |
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 |
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: 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