Elite Bronze + Vision + Adult Dental - 62141AR0100026 Health Insurance Plan
Celtic Insurance Company health insurance plan with the Plan ID 62141AR0100026. The plan is called Elite Bronze + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.72% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.28% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 62141AR0100026 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Arkansas | ||||||||||||||||||
| Health Insurance Issuer | Celtic Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 62141AR0100026-01 | ||||||||||||||||||
| 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 - 62141AR0100026-00 Standard On Exchange Plan - 62141AR0100026-01 |
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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 Elite Bronze + Vision + Adult Dental Health Insurance Plan, 62141AR0100026-01
| 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 | 50.00% |
60.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $115.00 |
60.00% Coinsurance after deductible |
| Applied Behavior Analysis Based Therapies
|
YES | 50.00% |
60.00% Coinsurance after deductible |
| 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% |
50.00% |
| Basic Dental Care - Child
|
NO | ||
| Cardiac Rehabilitation
Limit: 36.0 Visit(s) per Year |
YES | 50.00% |
60.00% Coinsurance after deductible |
| Chemotherapy
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% |
60.00% 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 | $80.00 |
60.00% Coinsurance after deductible |
| Cochlear Implants
|
YES | 50.00% |
60.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Craniofacial Surgery
|
YES | $3,000.00 |
60.00% 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 | $3,000.00 |
60.00% Coinsurance after deductible |
| Dental Anesthesia
|
YES | 50.00% |
60.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | $115.00 |
60.00% Coinsurance after deductible |
| Diabetes Education
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $115.00 |
60.00% Coinsurance after deductible |
| Dialysis
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% |
60.00% Coinsurance after deductible |
| Durable Medical Equipment
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% |
60.00% Coinsurance after deductible |
| 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 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% |
60.00% Coinsurance after deductible |
| Gender Affirming Care
|
YES | $3,000.00 |
60.00% 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 | $3.00 |
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% |
60.00% Coinsurance after deductible |
| 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 | 50.00% |
60.00% |
| 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% |
60.00% Coinsurance after deductible |
| Hospice Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% |
60.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% |
60.00% Coinsurance after deductible |
| Infertility Treatment
Prior authorization may be required. Coverage includes testing to diagnose infertility, infertility counseling and planning services; also, in vitro fertilization procedures are covered. |
YES | 50.00% |
60.00% Coinsurance after deductible |
| Infusion Therapy
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% |
60.00% Coinsurance after deductible |
| Inherited Metabolic Disorder - PKU
|
YES | $60.00 |
60.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $3,000.00 Copay per Day |
60.00% 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 |
60.00% 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 |
60.00% Coinsurance after deductible |
| 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% |
50.00% |
| 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 |
60.00% 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 | 50.00% |
60.00% Coinsurance after deductible |
| 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 | $50.00 |
60.00% Coinsurance after deductible |
| Mental/Behavioral Health Urgent Care
|
YES | $50.00 |
60.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
|
YES | $250.00 Copay after deductible |
100.00% |
| Nutritional Counseling
|
YES | $115.00 |
60.00% Coinsurance after deductible |
| Off Label Prescription Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $50.00 |
60.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% |
60.00% 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% |
60.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% |
60.00% Coinsurance after deductible |
| Preferred Brand Drugs
|
YES | $195.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $50.00 |
60.00% Coinsurance after deductible |
| Preventative Drugs
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Covered in accordance with ACA guidelines. |
YES | No Charge |
60.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $50.00 |
60.00% Coinsurance after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% |
60.00% Coinsurance after deductible |
| Radiation
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% |
60.00% 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 | $3,000.00 |
60.00% 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% |
60.00% Coinsurance after deductible |
| 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% |
60.00% Coinsurance after deductible |
| 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 |
No Charge |
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year OON exam: Up to $38.50. 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 eyeglasses. OON eyewear benefit: covered up to $50 for frames, lenses up to $37.50 and contact lenses up to $91. |
YES | No Charge |
No Charge |
| 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 | $115.00 |
60.00% Coinsurance after deductible |
| Skilled Nursing Facility
Limit: 60.0 Days per Year Prior authorization may be required - please contact the number listed on your ID card. |
YES | $3,000.00 Copay per Day |
60.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $115.00 |
60.00% Coinsurance after deductible |
| 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 |
60.00% 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 | $50.00 |
60.00% Coinsurance after deductible |
| 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
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 | 50.00% |
60.00% Coinsurance after deductible |
| Substance Use Disorder Urgent Care
|
YES | $50.00 |
60.00% Coinsurance after deductible |
| 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
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $3,000.00 |
60.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% |
60.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
|
YES | $60.00 |
60.00% Coinsurance after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
60.00% |
| Well Child Care
|
YES | No Charge |
60.00% |
| X-rays and Diagnostic Imaging
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 50.00% |
60.00% Coinsurance after deductible |
Elite Bronze + Vision + Adult Dental Health Insurance Plan Variant 62141AR0100026-01 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 | 0.965649944220338 |
| First Tier Utilization | 100% |
| Formulary ID | ARF004 |
| Formulary URL | URL |
| HIOS Product ID | 62141AR010 |
| 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 | 64.72% |
| Issuer ID | 62141 |
| 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 | $16900 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $8450 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $8,450 |
| 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 | $16900 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $8450 per person |
| Medical EHB Deductible, Out of Network, Individual | $8,450 |
| Metal Level | Expanded Bronze |
| 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) | 62141AR0100026-01 |
| Plan Marketing Name | Elite Bronze + Vision + Adult Dental |
| Plan Type | PPO |
| Plan Variant Marketing Name | Elite Bronze + Vision + Adult Dental |
| 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 | $3,400 |
| 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 | ARS001 |
| Source Name | SERFF |
| Plan ID | 62141AR0100026 |
| State Code | AR |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $42400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $21200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $21,200 |
| 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 | $24000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $12000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $12,000 |
| 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 + Vision + Adult Dental Health Insurance Plan, 62141AR0100026
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Elite Bronze + Vision + Adult Dental, 62141AR0100026 Health Insurance Plan, 62141AR0100026
-
Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, 62141AR0100026 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (62141AR0100026) Health Insurance Plan, Variant (62141AR0100026-01) offer Disease Management Programs?
Does (62141AR0100026) Health Insurance Plan, Variant (62141AR0100026-01) have Out Of Country Coverage?
Does (62141AR0100026) Health Insurance Plan, Variant (62141AR0100026-01) have Out of Service Area Coverage?
Does (62141AR0100026) Health Insurance Plan, Variant (62141AR0100026-01) offer Disease Management Programs?
Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, Variant (62141AR0100026-01) offer Disease Management Programs for Asthma?
Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, Variant (62141AR0100026-01) offer Disease Management Programs for Heart disease?
Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, Variant (62141AR0100026-01) offer Disease Management Programs for Diabetes?
Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, Variant (62141AR0100026-01) 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