Connected Silver (QualChoice) - 70525AR0070261 Health Insurance Plan
QCA Health Plan, Inc. health insurance plan with the Plan ID 70525AR0070261. The plan is called Connected Silver (QualChoice).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.07% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.93% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 70525AR0070261 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Arkansas | ||||||||||||||||||
| Health Insurance Issuer | QCA Health Plan, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 70525AR0070261-00 | ||||||||||||||||||
| 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 - 70525AR0070261-00 Standard On Exchange Plan - 70525AR0070261-01 Open to Indians below 300% FPL - 70525AR0070261-02 Open to Indians above 300% FPL - 70525AR0070261-03 73% AV Silver Plan - 70525AR0070261-04 |
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| Last Plan Update Date | Mon, 12 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Connected Silver (QualChoice) Health Insurance Plan, 70525AR0070261-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $250.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $75.00 |
50.00% |
| Applied Behavior Analysis Based Therapies
|
YES | $250.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Cardiac Rehabilitation
Limit: 36.0 Visit(s) per Year |
YES | $50.00 |
50.00% |
| Chemotherapy
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $250.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | $75.00 |
50.00% |
| Cochlear Implants
|
YES | $50.00 |
50.00% |
| Cosmetic Surgery
|
NO | ||
| Craniofacial Surgery
|
YES | $1000.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $1000.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Dental Anesthesia
|
YES | $250.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | $75.00 |
50.00% |
| Diabetes Education
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $75.00 |
50.00% |
| Dialysis
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $250.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $50.00 |
50.00% |
| Emergency Room Services
|
YES | $250.00 Copay after deductible |
$250.00 Copay after deductible |
| Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | $750.00 Copay after deductible |
$750.00 Copay after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year OON: Up to $50 for frames, $37.50 for lenses and $91 for contacts in lieu of eyeglasses. See EOC for lens limits. |
YES | No Charge |
No Charge |
| Gastric Electrical Stimulation
|
YES | $50.00 |
50.00% |
| Gender Affirming Care
|
YES | $1000.00 Copay after deductible |
50.00% Coinsurance after deductible |
| 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 | $15.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Prior authorization may be required - please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient habilitation services; limited to 180 visits per year for developmental services. |
YES | $50.00 |
50.00% |
| Hearing Aids
Limit: 2.0 Item(s) per 3 Years Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge |
50.00% |
| Home Health Care Services
Limit: 50.0 Visit(s) per Year Prior authorization may be required - please contact the number listed on your ID card. |
YES | $50.00 |
50.00% |
| Hospice Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $100.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $150.00 |
50.00% |
| 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). |
NO | ||
| Infusion Therapy
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $250.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Inherited Metabolic Disorder - PKU
|
YES | $60.00 |
50.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $1,000.00 Copay per Day after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $60.00 |
50.00% |
| 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
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Emergency Room
|
YES | $125.00 Copay after deductible |
$125.00 Copay 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 | $125.00 Copay after deductible |
$125.00 Copay after deductible |
| Mental/Behavioral Health ER Physician Fee
|
YES | $125.00 Copay after deductible |
$125.00 Copay after deductible |
| Mental/Behavioral Health Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $1,000.00 Copay per Day after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Other Services
Prior authorization may be required - please contact the number listed on your ID card. Note: Cost share will be waived for Behavioral Health screening services. |
YES | No Charge |
50.00% |
| 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. Cost share will be waived for Behavioral Health screening services. |
YES | $55.00 |
50.00% |
| Mental/Behavioral Health Urgent Care
|
YES | $50.00 |
50.00% |
| Non-Preferred Brand Drugs
|
YES | $100.00 Copay after deductible |
100.00% |
| Nutritional Counseling
|
YES | $75.00 |
50.00% |
| Off Label Prescription Drugs
|
YES | $250.00 Copay after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $55.00 |
50.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $250.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Prior authorization may be required - please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | $50.00 |
50.00% |
| Outpatient Surgery Physician/Surgical Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $100.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
|
YES | $50.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $55.00 |
50.00% |
| Preventative Drugs
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Covered in accordance with ACA guidelines. |
YES | No Charge |
50.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $55.00 |
50.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $50.00 |
50.00% |
| Radiation
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $250.00 Copay after deductible |
50.00% Coinsurance after deductible |
| 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 | $1000.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year 60 inpatient days/year. Prior authorization may be required - please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | $50.00 |
50.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Prior authorization may be required - please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | $50.00 |
50.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Up to $38.50 OON |
YES | No Charge |
No Charge |
| Routine Foot Care
|
YES | $75.00 |
50.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Year Prior authorization may be required - please contact the number listed on your ID card. |
YES | $100.00 Copay per Day after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $75.00 |
50.00% |
| Specialty Drugs
|
YES | $250.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $1,000.00 Copay per Day after deductible |
50.00% Coinsurance after deductible |
| 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. Cost share will be waived for Behavioral Health screening services. |
YES | $55.00 |
50.00% |
| Substance Use Disorder Emergency Room
|
YES | $125.00 Copay after deductible |
$125.00 Copay 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 | $125.00 Copay after deductible |
$125.00 Copay after deductible |
| Substance Use Disorder ER Physician Fee
|
YES | $125.00 Copay after deductible |
$125.00 Copay after deductible |
| Substance Use Disorder Outpatient Other Services
Prior authorization may be required - please contact the number listed on your ID card. Note: Cost share will be waived for Behavioral Health screening services. |
YES | No Charge |
50.00% |
| Substance Use Disorder Urgent Care
|
YES | $50.00 |
50.00% |
| 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 | $15.00 |
100.00% |
| Transplant
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $1000.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $250.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
|
YES | $60.00 |
50.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
50.00% |
| Well Child Care
|
YES | No Charge |
50.00% |
| X-rays and Diagnostic Imaging
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $60.00 |
50.00% |
Connected Silver (QualChoice) Health Insurance Plan Variant 70525AR0070261-00 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 Silver Off Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $2000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1000 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $1,000 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 0.9999399999999999 |
| First Tier Utilization | 100% |
| Formulary ID | ARF002 |
| Formulary URL | URL |
| HIOS Product ID | 70525AR007 |
| 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 | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 70.07% |
| Issuer ID | 70525 |
| Issuer Marketplace Marketing Name | Ambetter from Arkansas Health & Wellness |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | $31000 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $15500 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $15,500 |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $14700 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $7350 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $7,350 |
| Medical EHB Deductible, Out of Network, Family Per Group | $16300 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $8150 per person |
| Medical EHB Deductible, Out of Network, Individual | $8,150 |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | ARN001 |
| 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) | 70525AR0070261-00 |
| Plan Marketing Name | Connected Silver (QualChoice) |
| Plan Type | POS |
| Plan Variant Marketing Name | Connected Silver (QualChoice) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,700 |
| SBC Scenario, Having a Baby, Deductible | $7,350 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $2,000 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,700 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ARS001 |
| Source Name | SERFF |
| Plan ID | 70525AR0070261 |
| State Code | AR |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $41200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $20600 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $20,600 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $23000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $11500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $11,500 |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Connected Silver (QualChoice) Health Insurance Plan, 70525AR0070261
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Connected Silver (QualChoice), 70525AR0070261 Health Insurance Plan, 70525AR0070261
-
Does Connected Silver (QualChoice) Health Insurance Plan, 70525AR0070261 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (70525AR0070261) Health Insurance Plan, Variant (70525AR0070261-00) offer Disease Management Programs?
Does (70525AR0070261) Health Insurance Plan, Variant (70525AR0070261-00) have Out Of Country Coverage?
Does (70525AR0070261) Health Insurance Plan, Variant (70525AR0070261-00) have Out of Service Area Coverage?
Does (70525AR0070261) Health Insurance Plan, Variant (70525AR0070261-00) offer Disease Management Programs?
Does Connected Silver (QualChoice) Health Insurance Plan, Variant (70525AR0070261-00) offer Disease Management Programs for Asthma?
Does Connected Silver (QualChoice) Health Insurance Plan, Variant (70525AR0070261-00) offer Disease Management Programs for Heart disease?
Does Connected Silver (QualChoice) Health Insurance Plan, Variant (70525AR0070261-00) offer Disease Management Programs for Diabetes?
Does Connected Silver (QualChoice) Health Insurance Plan, Variant (70525AR0070261-00) 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