Celtic Insurance Company health insurance plan with the Plan ID 27833IL0150013. The plan is called Complete Silver + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.18% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.82% of the costs of all covered benefits (according to the Issuer).
Health Insurance Plan ID | 27833IL0150013 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Illinois | ||||||||||||||||||
Health Insurance Issuer | Celtic Insurance Company | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 27833IL0150013-03 | ||||||||||||||||||
Provider Network(s) | ['ILN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 27 Aug 2024 05:58 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 27833IL0150013-00 Standard On Exchange Plan - 27833IL0150013-01 Open to Indians below 300% FPL - 27833IL0150013-02 Open to Indians above 300% FPL - 27833IL0150013-03 73% AV Silver Plan - 27833IL0150013-04 |
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Last Plan Update Date | Thu, 23 Feb 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 27 Aug 2024 05:58 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Accidental Dental
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | $60.00 |
100.00% |
Autism Spectrum Disorders
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Bariatric Surgery
|
YES | 40.00% Coinsurance after deductible |
100.00% |
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; Excluded from the In-Network MOOP |
YES | 50.00% |
100.00% |
Basic Dental Care - Child
|
NO | ||
Bones/Joints
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Breast Implant Removal
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Cardiac Rehabilitation
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Chemotherapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
Limit: 25.0 Visit(s) per Year |
YES | $60.00 |
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 | 40.00% Coinsurance after deductible |
100.00% |
Delivery and All Inpatient Services for Maternity Care
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Dental Anesthesia
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Education
|
YES | $60.00 |
100.00% |
Dialysis
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Eyeglasses for Adults
Limit: 1.0 Item(s) per Year Covered up to $130; Excluded from In-Network MOOP |
YES | No Charge |
100.00% |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
Gender Affirming Care
|
YES | 40.00% 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 | $18.20 |
100.00% |
Habilitation Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Hearing Aids
Limit: 2.0 Item(s) per 2 Years |
YES | 40.00% Coinsurance after deductible |
100.00% |
Home Health Care Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Hospice Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
Cost share is based on place of service. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Infusion Therapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Inherited Metabolic Disorder - PKU
|
YES | $30.00 |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
Cost share is based on place of service. |
YES | $30.00 |
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; Excluded from the In-Network MOOP |
YES | 50.00% |
100.00% |
Major Dental Care - Child
Limitations vary based on procedures. |
NO | ||
Mental/Behavioral Health Emergency Room
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Mental/Behavioral Health Emergency Transportation/Ambulance
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Mental/Behavioral Health ER Physician Fee
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Mental/Behavioral Health Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Other Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
|
YES | $30.00 |
100.00% |
Mental/Behavioral Health Urgent Care
|
YES | $30.00 |
100.00% |
Multiple Sclerosis
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Naprapathic Service
Limit: 15.0 Visit(s) per Year |
YES | $60.00 |
100.00% |
Non-Preferred Brand Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Nutritional Counseling
|
YES | $60.00 |
100.00% |
Organ Transplants
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Limitations vary based on procedures. |
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
|
YES | $55.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | $30.00 |
100.00% |
Prescription Drugs Other
|
YES | 50.00% Coinsurance after deductible |
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 | $30.00 |
100.00% |
Private-Duty Nursing
Available on an outpatient basis only (inpatient excluded) |
YES | 40.00% Coinsurance after deductible |
100.00% |
Prosthetic Devices
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Rehabilitative Speech Therapy
|
YES | 40.00% 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; Excluded from the In-Network MOOP |
YES | No Charge |
100.00% |
Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Year Excluded from In Network MOOP |
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 | $60.00 |
100.00% |
Skilled Nursing Facility
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | $60.00 |
100.00% |
Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
100.00% |
Substance Use Disorder Emergency Room
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Substance Use Disorder Emergency Transportation/Ambulance
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Substance Use Disorder ER Physician Fee
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Substance Use Disorder Outpatient Other Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Substance Use Disorder Urgent Care
|
YES | $30.00 |
100.00% |
Transplant
Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | $60.00 |
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 | 40.00% 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, Diabetes, Pregnancy |
EHB Percent of Total Premium | 0.9612 |
First Tier Utilization | 100% |
Formulary ID | ILF003 |
Formulary URL | URL |
HIOS Product ID | 27833IL015 |
Import Date | 2/23/2023 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? | Yes |
Issuer Actuarial Value | 71.18% |
Issuer ID | 27833 |
Issuer Marketplace Marketing Name | Ambetter of Illinois |
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 | ILN001 |
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) | 27833IL0150013-03 |
Plan Marketing Name | Complete Silver + Vision + Adult Dental |
Plan Type | HMO |
Plan Variant Marketing Name | Complete Silver + 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 | ILS001 |
Source Name | SERFF |
Specialist Requiring a Referral | All except for mental or behavioral health services, obstetrical or gynecological treatment. |
Plan ID | 27833IL0150013 |
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 | 40.00% |
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 | $17000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8500 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,500 |
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 |
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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, 27 Aug 2024 05:58 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