Celtic Insurance Company health insurance plan with the Plan ID 34368KS0120002. The plan is called Complete Gold + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.50% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.50% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.97% (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 18.03% 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 | 34368KS0120002 | ||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Kansas | ||||||||||||||||||
Health Insurance Issuer | Celtic Insurance Company | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 34368KS0120002-03 | ||||||||||||||||||
Provider Network(s) | ['KSN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Sep 2024 06:24 GMT). |
|
||||||||||||||||||
Available Variants of the Health Plan | Standard Off Exchange Plan - 34368KS0120002-00 Standard On Exchange Plan - 34368KS0120002-01 |
||||||||||||||||||
Last Plan Update Date | Fri, 23 Jun 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 24 Sep 2024 06:24 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
Oral Surgical Services and Services for Accidental Injuries to Sound Natural Teeth, limited to: (1) Surgical procedures of the jaw and gums. (2) Removal of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth. (3) Removal of exostoses (bony growths) of the jaw and hard palate. (4) Treatment of fractures and dislocations of the jaw and facial bones. (5) Surgical removal of impacted teeth. (6) Treatment of Sound Natural Teeth caused by an Accidental Injury. This includes replacement of Sound Natural Teeth lost due to the Accidental Injury. (7) Intra oral dental imaging services in connection with covered oral surgery if treatment begins within 30 days. (8) General anesthesia for covered oral surgery. (9) Cylindrical endosseous dental implants, mandibular staple implants, subperiosteal implants and the associated fixed and/or removable prosthetic appliance when provided because of an Accidental Injury. (10) Cylindrical endosseous dental implants, mandibular staple implants, subperiosteal implants andthe associated fixed and/or removable prosthetic appliances following surgical resection of either benign or malignant lesions (NOT including inflammatory lesions). |
YES | 20.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
Allergy testing and treatment. |
YES | $35.00 |
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 | 20.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
|
YES | $35.00 |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Education
Outpatient self-management training and education, including medical nutrition therapy, for insulin dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin using diabetes when provided by a certified, registered or licensed health care professional with expertise in diabetes and the diabetic (1) is treated at a program approved by the American Diabetes Association; (2) is treated by a person certified by the national certification board of diabetes educators; or (3) is, as to nutritional education, treated by a licensed dietitian pursuant to a treatment plan authorized by such healthcare professional. |
YES | $35.00 |
100.00% |
Dialysis
Plan cover Hemodialysis. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
Eye Glasses for Adults
Limit: 1.0 Item(s) per Year Covered up to $130 |
YES | No Charge |
100.00% |
Eye Glasses for Children
Limit: 3.0 Item(s) per Year |
YES | No Charge |
100.00% |
Gender Affirming Care
|
YES | 20% Coinsurance after deductible |
100.00% |
Generic Drugs
Most Ambetter Plans offer Preferred Generic Drugs at $5 or less. Please see plan's Summary of Benefits and Coverage (SBC) or policy document for Preferred Generic and Generic prescription drug cost. |
YES | $13.80 |
100.00% |
Habilitation Services
Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Hearing Aids
Hearing Aids are a non-covered benefit. Coverage is available only for Cochlear Implants and Bone Anchored Hearing Aids. |
NO | ||
Home Health Care Services
Includes educational visits with a limit of three per year on educational visits. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Hospice Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
Cost share is based on place of service. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
Plan covers Diagnosis and treatment of cause of infertility. Benefits are available for covered services such as office visits, laboratory tests, and radiological studies to diagnose the cause of infertility. Benefits are also provided for the necessary treatment of the condition unless the treatment is identified as non-covered (see exclusions). For example, corrective surgical procedures, therapeutic injections, and drug therapy regimens (Pregnyl, Clomid, Clomiphene, Ovidrel, Gonal, Follistim and Cetrotide) are all covered services when medically necessary. Benefits are also available for tests, such as ultrasound, performed to monitor the effectiveness of the fertility drug therapy. Also for any necessary pregnancy testing performed as an integral part of the overall infertility treatment program. Benefits are excluded, however, for any procedures, tests, or other services that are exclusively provided to monitor the effectiveness of non-covered fertilization procedures. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Infusion Therapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
Cost share is based on place of service. |
YES | $15.00 |
100.00% |
Long-Term/Custodial Nursing Home Care
Long Term Acute Care is a covered benefit.? Long Term Nursing Care/ Custodial Care is not a covered benefit. |
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
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
Mental/Behavioral Health Emergency Transportation/Ambulance
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
Mental/Behavioral Health ER Physician Fee
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
Mental/Behavioral Health Inpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Other Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
|
YES | $15.00 |
100.00% |
Mental/Behavioral Health Urgent Care
|
YES | $35.00 |
100.00% |
Non-Preferred Brand Drugs
|
YES | 30.00% Coinsurance after deductible |
100.00% |
Nutritional Counseling
|
NO | ||
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Orthodontic services require prior authorization and are only covered for eligible children with cases of severe orthodontic abnormality caused by genetic deformity (such as cleft lip or cleft palate) or traumatic facial injury resulting in serious health impairment to the beneficiary at the present time. |
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $15.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 90.0 Visit(s) per Year These therapies include but are not limited to PT, OT, and ST. Further, '(Rehab) services are covered only if they are expected to result in significant improvement in the Insured's condition. The Company, with appropriate medical consultation, will determine whether significant improvement has occurred'. 'Speech Therapy', limited to one service per day up to a maximum benefit of 90 daily services per Insured per Benefit Period. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
|
YES | $30.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | $15.00 |
100.00% |
Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs. |
YES | $15.00 |
100.00% |
Private-Duty Nursing
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Prosthetic Devices
Limited to 4 mastectomy bras per year. Limited to 1 wig per year. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
Cosmetic and reconstructive are generally excluded, but excepted from this exclusion are: a. Cosmetic or reconstructive repair of an Accidental Injury.; b. Reconstructive breast surgery in connection with a Medically Necessary mastectomy that resulted from a medical illness or injury. This includes reconstructive surgery on a breast on which a mastectomy was not performed in order to produce a symmetrical appearance.; c. Repair of congenital abnormalities and hereditary complications or conditions, limited to: (1) Cleft lip or palate. (2) Birthmarks on head or neck. (3) Webbed fingers or toes. (4) Supernumerary fingers or toes.; d. Reconstructive services performed on structures of the body to improve/restore impairments of bodily function resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes. For purposes of this provision, the term 'cosmetic' means procedures and related services performed to reshape structures of the body in order to alter the individual's appearance. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Rehabilitative Speech Therapy
Limit: 90.0 Visit(s) per Year Limited to one service per day up to a maximum benefit of 90 daily services per Insured per Benefit Period. |
YES | 20.00% Coinsurance 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 Visit(s) per Year |
YES | No Charge |
100.00% |
Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
Routine Foot Care
Prior authorization may be required. Covered no limit. |
YES | $35.00 |
100.00% |
Skilled Nursing Facility
|
NO | ||
Specialist Visit
|
YES | $35.00 |
100.00% |
Specialty Drugs
|
YES | 30.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | $15.00 |
100.00% |
Substance Use Disorder Emergency Room
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
Substance Use Disorder Emergency Transportation/Ambulance
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
Substance Use Disorder ER Physician Fee
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
Substance Use Disorder Outpatient Other Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Substance Use Disorder Urgent Care
|
YES | $35.00 |
100.00% |
Transplant
Prior authorization may be required. Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | $35.00 |
100.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
Cost share is based on place of service. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.819728852 |
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, Diabetes, Pregnancy |
EHB Percent of Total Premium | 0.9646 |
First Tier Utilization | 100% |
Formulary ID | KSF002 |
Formulary URL | URL |
HIOS Product ID | 34368KS012 |
Import Date | 6/23/2023 20:01 |
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 Actuarial Value | 81.50% |
Issuer ID | 34368 |
Issuer Marketplace Marketing Name | Ambetter from Sunflower Health Plan |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Gold |
Multiple In Network Tiers | No |
National Network | No |
Network ID | KSN001 |
Out of Country Coverage | No |
Out of Service Area Coverage | No |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan ID (Standard Component ID with Variant) | 34368KS0120002-03 |
Plan Marketing Name | Complete Gold + Vision + Adult Dental |
Plan Type | EPO |
Plan Variant Marketing Name | Complete Gold + 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 | $0 |
SBC Scenario, Having a Baby, Limit | $0 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $0 |
SBC Scenario, Having Diabetes, Deductible | $0 |
SBC Scenario, Having Diabetes, Limit | $0 |
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 | $0 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | KSS001 |
Source Name | SERFF |
Plan ID | 34368KS0120002 |
State Code | KS |
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 | 20.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $2900 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1450 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,450 |
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 | $15000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7500 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,500 |
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 | Yes |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
---|
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, 24 Sep 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