Choice Bronze HSA + Vision + Adult Dental - 41047OH0030045 Health Insurance Plan
Buckeye Community Health Plan health insurance plan with the Plan ID 41047OH0030045. The plan is called Choice Bronze HSA + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 63.53% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 36.47% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 41047OH0030045 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Ohio | ||||||||||||||||||
| Health Insurance Issuer | Buckeye Community Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 41047OH0030045-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 41047OH0030045-00 Standard On Exchange Plan - 41047OH0030045-01 |
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| Last Plan Update Date | Mon, 12 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Choice Bronze HSA + Vision + Adult Dental Health Insurance Plan, 41047OH0030045-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Limit: 3000.0 Dollars per Episode Limited to $3,000 per occurrence. |
YES | No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
100.00% |
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge 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
|
NO | ||
| Diabetes Education
|
YES | No Charge after deductible |
100.00% |
| Dialysis
|
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
|
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | No Charge after deductible |
No Charge after deductible |
| ER Diagnostic Test Lab-work/Other
|
YES | No Charge after deductible |
No Charge after deductible |
| ER Diagnostic Test (X-Ray)
|
YES | No Charge after deductible |
No Charge after deductible |
| ER Imaging Test
|
YES | No Charge after deductible |
No Charge after deductible |
| ER Physician Fee
|
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Coverage includes benefits specified in the FEDVIP FEP Blue Vision High Option plan, including low vision benefits. |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | No Charge after deductible |
100.00% |
| Generic Drugs
Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information. |
YES | No Charge after deductible |
100.00% |
| Habilitation Services
No limit applies to outpatient habilitation services. Inpatient habilitation services are limited to 60 Days per year. |
YES | No Charge after deductible |
100.00% |
| Hearing Aids
Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit. |
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Hospice Services
Limited to 14 days per lifetime for respite care covered in conjunction with hospice services. |
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). |
YES | No Charge after deductible |
100.00% |
| Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
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
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
100.00% |
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Emergency Room
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health ER Physician Fee
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Urgent Care
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
|
YES | No Charge after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| 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: 116.0 Visit(s) per Year Per year, outpatient cardiac therapy is limited to 36 visits, outpatient pulmonary therapy is limited to 20 visits, outpatient speech, occupational and physical therapy are limited to 20 visits each. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | No Charge 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
Services with an 'A' or 'B' rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Unlimited Virtual 24/7 Care Visits received from Ambetter?s designated telehealth provider covered at No Charge, except for HSAs. |
YES | No Charge after deductible |
100.00% |
| Private-Duty Nursing
Limit: 90.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Prosthetic Devices
|
YES | No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality; 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year 20 visits per year each for outpatient physical & occupational therapy. Inpatient rehabilitation limited to 60 Days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year 20 visits per year for outpatient speech therapy. Inpatient rehabilitation limited to 60 Days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | No Charge after deductible |
100.00% |
| Routine Dental Services (Adult)
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eye glasses. |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Coverage includes benefits specified in the FEDVIP FEP Blue Vision High Option plan, including low vision benefits. |
YES | No Charge |
100.00% |
| Routine Foot Care
|
YES | No Charge after deductible |
100.00% |
| 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
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. |
YES | No Charge after deductible |
100.00% |
| Substance Use Disorder Emergency Room
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder ER Physician Fee
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder Outpatient Other Services
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | No Charge after deductible |
100.00% |
| Substance Use Disorder Urgent Care
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | No Charge after deductible |
100.00% |
| Tier 1b Generic Drugs
Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information. |
YES | No Charge after deductible |
100.00% |
| Transplant
Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
100.00% |
| 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% |
Choice Bronze HSA + Vision + Adult Dental Health Insurance Plan Variant 41047OH0030045-00 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 | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 0.9717 |
| First Tier Utilization | 100% |
| Formulary ID | OHF003 |
| Formulary URL | URL |
| HIOS Product ID | 41047OH003 |
| Import Date | 2024-08-12 20:01:40 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 63.53% |
| Issuer ID | 41047 |
| Issuer Marketplace Marketing Name | Ambetter 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 | OHN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 41047OH0030045-00 |
| Plan Marketing Name | Choice Bronze HSA + Vision + Adult Dental |
| Plan Type | HMO |
| Plan Variant Marketing Name | Choice Bronze HSA + Vision + Adult Dental |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,250 |
| 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 | OHS001 |
| Source Name | SERFF |
| Plan ID | 41047OH0030045 |
| State Code | OH |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $14500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7250 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,250 |
| 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 | $14500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7250 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,250 |
| 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 | No |
Copay & Coinsurance of Choice Bronze HSA + Vision + Adult Dental Health Insurance Plan, 41047OH0030045
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Choice Bronze HSA + Vision + Adult Dental, 41047OH0030045 Health Insurance Plan, 41047OH0030045
-
Does Choice Bronze HSA + Vision + Adult Dental Health Insurance Plan, 41047OH0030045 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (41047OH0030045) Health Insurance Plan, Variant (41047OH0030045-00) offer Disease Management Programs?
Does (41047OH0030045) Health Insurance Plan, Variant (41047OH0030045-00) have Out Of Country Coverage?
Does (41047OH0030045) Health Insurance Plan, Variant (41047OH0030045-00) have Out of Service Area Coverage?
Does (41047OH0030045) Health Insurance Plan, Variant (41047OH0030045-00) offer Disease Management Programs?
Does Choice Bronze HSA + Vision + Adult Dental Health Insurance Plan, Variant (41047OH0030045-00) offer Disease Management Programs for Asthma?
Does Choice Bronze HSA + Vision + Adult Dental Health Insurance Plan, Variant (41047OH0030045-00) offer Disease Management Programs for Heart disease?
Does Choice Bronze HSA + Vision + Adult Dental Health Insurance Plan, Variant (41047OH0030045-00) offer Disease Management Programs for Diabetes?
Does Choice Bronze HSA + Vision + Adult Dental Health Insurance Plan, Variant (41047OH0030045-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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