Elite Bronze - 90787LA0010002 Health Insurance Plan
Ambetter Health of Louisiana, Inc. health insurance plan with the Plan ID 90787LA0010002. The plan is called Elite Bronze.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.74% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.26% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 90787LA0010002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Louisiana | ||||||||||||||||||
| Health Insurance Issuer | Ambetter Health of Louisiana, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 90787LA0010002-01 | ||||||||||||||||||
| 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 - 90787LA0010002-00 Standard On Exchange Plan - 90787LA0010002-01 |
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| Last Plan Update Date | Tue, 13 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Elite Bronze Health Insurance Plan, 90787LA0010002-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 50.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $115.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% |
100.00% |
| Chiropractic Care
|
YES | $80.00 |
100.00% |
| Cosmetic Surgery
See Reconstructive Surgery. |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | $3,000.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $115.00 |
100.00% |
| Dialysis
|
YES | 50.00% |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% |
100.00% |
| Emergency Room Services
|
YES | $2,500.00 |
$2,500.00 |
| Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | 50.00% |
50.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | $3,000.00 |
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 | $3.00 |
100.00% |
| Habilitation Services
|
YES | 50.00% |
100.00% |
| Hearing Aids
Limit: 2.0 Item(s) per 3 Years Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit. One hearing aid per ear every 3 years. |
YES | 50.00% |
100.00% |
| Home Health Care Services
|
YES | 50.00% |
100.00% |
| Hospice Services
Respite Care is not a covered benefit. |
YES | 50.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% |
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). |
NO | ||
| Infusion Therapy
|
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $3,000.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $60.00 |
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
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Emergency Room
|
YES | $1,250.00 |
$1,250.00 |
| Mental/Behavioral Health Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | $1,250.00 |
$1,250.00 |
| Mental/Behavioral Health ER Physician Fee
|
YES | $1,250.00 |
$1,250.00 |
| Mental/Behavioral Health Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $3,000.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
|
YES | 50.00% |
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 | $60.00 |
100.00% |
| Mental/Behavioral Health Urgent Care
|
YES | $50.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | $115.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $60.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% |
100.00% |
| Outpatient Rehabilitation Services
|
YES | 50.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% |
100.00% |
| Preferred Brand Drugs
|
YES | $195.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $60.00 |
100.00% |
| Preventive Care/Screening/Immunization
Covered in accordance with ACA guidelines. |
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 | $60.00 |
100.00% |
| Private-Duty Nursing
Available on home and outpatient basis only (inpatient excluded). |
YES | 50.00% |
100.00% |
| Prosthetic Devices
|
YES | 50.00% |
100.00% |
| Radiation
|
YES | 50.00% |
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. |
YES | $3,000.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | 50.00% |
100.00% |
| Rehabilitative Speech Therapy
|
YES | 50.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
YES | $115.00 |
100.00% |
| Skilled Nursing Facility
|
YES | $3,000.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $115.00 |
100.00% |
| Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $3,000.00 Copay per Day |
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 | $60.00 |
100.00% |
| Substance Use Disorder Emergency Room
|
YES | $1,250.00 |
$1,250.00 |
| Substance Use Disorder Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | $1,250.00 |
$1,250.00 |
| Substance Use Disorder ER Physician Fee
|
YES | $1,250.00 |
$1,250.00 |
| Substance Use Disorder Outpatient Other Services
|
YES | 50.00% |
100.00% |
| Substance Use Disorder Urgent Care
|
YES | $50.00 |
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 | $35.00 |
100.00% |
| Transplant
Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | $3,000.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $60.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Covered in accordance with ACA guidelines. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 50.00% |
100.00% |
Elite Bronze Health Insurance Plan Variant 90787LA0010002-01 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 On 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 | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $7600 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3800 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $3,800 |
| 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 | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | LAF002 |
| Formulary URL | URL |
| HIOS Product ID | 90787LA001 |
| Import Date | 2024-08-13 01:01:24 |
| 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 | 64.74% |
| Issuer ID | 90787 |
| Issuer Marketplace Marketing Name | Ambetter from Louisiana Healthcare Connections |
| 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 | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | LAN001 |
| 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) | 90787LA0010002-01 |
| Plan Marketing Name | Elite Bronze |
| Plan Type | EPO |
| Plan Variant Marketing Name | Elite Bronze |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $200 |
| SBC Scenario, Having a Baby, Copayment | $3,600 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $400 |
| SBC Scenario, Having Diabetes, Copayment | $3,500 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $800 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | LAS001 |
| Source Name | HIOS |
| Plan ID | 90787LA0010002 |
| State Code | LA |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| 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 Elite Bronze Health Insurance Plan, 90787LA0010002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Elite Bronze, 90787LA0010002 Health Insurance Plan, 90787LA0010002
-
Does Elite Bronze Health Insurance Plan, 90787LA0010002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (90787LA0010002) Health Insurance Plan, Variant (90787LA0010002-01) offer Disease Management Programs?
Does (90787LA0010002) Health Insurance Plan, Variant (90787LA0010002-01) have Out Of Country Coverage?
Does (90787LA0010002) Health Insurance Plan, Variant (90787LA0010002-01) have Out of Service Area Coverage?
Does (90787LA0010002) Health Insurance Plan, Variant (90787LA0010002-01) offer Disease Management Programs?
Does Elite Bronze Health Insurance Plan, Variant (90787LA0010002-01) offer Disease Management Programs for Asthma?
Does Elite Bronze Health Insurance Plan, Variant (90787LA0010002-01) offer Disease Management Programs for Heart disease?
Does Elite Bronze Health Insurance Plan, Variant (90787LA0010002-01) offer Disease Management Programs for Diabetes?
Does Elite Bronze Health Insurance Plan, Variant (90787LA0010002-01) 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