HA Bronze Suitcase - 13262AR0230006 Health Insurance Plan
HMO Partners, Inc. health insurance plan with the Plan ID 13262AR0230006. The plan is called HA Bronze Suitcase.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.78% (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 35.22% 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 | 13262AR0230006 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Arkansas | ||||||||||||||||||
| Health Insurance Issuer | HMO Partners, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 13262AR0230006-03 | ||||||||||||||||||
| Provider Network(s) | PREFERRED TRUE-BLUE-PPO | ||||||||||||||||||
| 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 - 13262AR0230006-00 Standard On Exchange Plan - 13262AR0230006-01 |
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| Last Plan Update Date | Mon, 11 Sep 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of HA Bronze Suitcase Health Insurance Plan, 13262AR0230006-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge after deductible |
No Charge after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
SOB includes 'allergy services.' |
YES | No Charge after deductible |
No Charge after deductible |
| Applied Behavior Analysis Based Therapies
|
YES | No Charge after deductible |
No Charge after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge after deductible |
No Charge after deductible |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $45.00 |
100.00% |
| Cochlear Implants
One cochlear implant per ear per Covered Person per lifetime |
YES | No Charge after deductible |
No Charge after deductible |
| Cosmetic Surgery
|
NO | ||
| Craniofacial Surgery
|
YES | No Charge after deductible |
No Charge after deductible |
| Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services: 13262AR0230006-01-No charge for in-network services and out-of-network services; 13262AR0230006-02-No charge for in-network and out-of-network services; 13262AR0230006-03-No charge for in-network and out-of-network services; Coverage for Out of Network newborn services is limited to $2000 per person for all services first 90 days after birth. Coverage requires Prior Notification to Health Advantage. |
YES | No Charge after deductible |
No Charge after deductible |
| Dental Anesthesia
|
YES | No Charge after deductible |
No Charge after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | No Charge after deductible |
No Charge after deductible |
| Diabetes Education
|
YES | No Charge |
No Charge after deductible |
| Dialysis
|
YES | No Charge after deductible |
No Charge after deductible |
| Durable Medical Equipment
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge after deductible |
No Charge after deductible |
| Gastric Electrical Stimulation
|
YES | No Charge after deductible |
No Charge after deductible |
| Gender Affirming Care
|
YES | No Charge after deductible |
100.00% |
| Generic Drugs
Mail Order cost: 13262AR023006-01- $60 Copay in-network, and 13262AR023006-03- $60 Copay in-network |
YES | $30.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro; Limited to a maximum of 180 units for developmental services visits per Covered Person per calendar year. Coverage includes 3 free visits for Outpatient Habilitation consultation and evaluation in-network services before copay applies. |
YES | $45.00 |
100.00% |
| Hearing Aids
Coverage is limited to $1400/ear |
YES | No Charge |
No Charge |
| Home Health Care Services
Limit: 50.0 Visit(s) per Year Coverage is provided for Home Health Services when Coverage Policy supports the need for in-home service and such care is prescribed or ordered by a Physician. Covered Services must be provided through and billed by a licensed home health agency. Covered Services provided in the home include services of a Registered Professional Nurse (R.N.), a Licensed Practical Nurse (L.P.N.) or a Licensed Psychiatric Technical Nurse (L.P.T.N.). |
YES | No Charge after deductible |
No Charge after deductible |
| Hospice Services
If the Covered Person has been diagnosed and certified by the attending Physician as having a terminal illness with a life expectancy of six months or less, Health Advantage will pay the Allowance or Allowable Charge for Hospice Care. The services must be rendered by an entity licensed by the Arkansas Department of Health or other appropriate state licensing agency and accepted by Health Advantage as a Provider. This benefit is subject to the Deductible, Copayment and Coinsurance specified in the Schedule of Benefits. |
YES | No Charge after deductible |
No Charge after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
No Charge after deductible |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Home infusion therapy. |
YES | No Charge after deductible |
No Charge after deductible |
| Inherited Metabolic Disorder - PKU
|
YES | No Charge after deductible |
No Charge after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
No Charge after deductible |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Outpatient Services
Coverage includes 3 free visits for Outpatient Mental Health consultation and evaluation in-network services before copay applies. Cost Sharing does NOT apply to screenings. |
YES | $45.00 |
No Charge after deductible |
| Non-Preferred Brand Drugs
Mail Order cost: 13262AR023006-01- $3200 Copay in-network, and 13262AR023006-03- $3200 Copay in-network |
YES | $1,600.00 |
100.00% |
| Nutritional Counseling
Coverage is provided for dietary and nutritional counseling services when provided in conjunction with diabetic self-management training, for services needed by covered persons in connection with cleft palate management and for nutritional assessment programs provided in and by a hospital and approved by Health Advantage. |
YES | No Charge after deductible |
No Charge after deductible |
| Off Label Prescription Drugs
|
YES | No Charge after deductible |
No Charge after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $45.00 |
No Charge after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
No Charge after deductible |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. Coverage includes 3 free visits for Outpatient Rehabiliation consultation and evaluation in-network services before copay applies |
YES | $45.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Preferred Brand Drugs
Mail Order cost: 13262AR023006-01- $420 Copay in-network, and 13262AR023006-03- $420 Copay in-network |
YES | $210.00 |
100.00% |
| Prenatal and Postnatal Care
Requires Prior Notification to Health Advantage. Coverage for routine ultrasound is limited to 1. |
YES | No Charge after deductible |
No Charge after deductible |
| Preventive Care/Screening/Immunization
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Preventive Drugs
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Coverage includes 3 free visits for Primary Care Physician consultation and evaluation in-network services before copay applies. |
YES | $45.00 |
No Charge after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Replaced no more frequently than once per 3-yr period except when necessary for growth or end of device's useful life. |
YES | No Charge after deductible |
No Charge after deductible |
| Radiation
|
YES | No Charge after deductible |
No Charge after deductible |
| Reconstructive Surgery
1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Covered Person; 2. Surgery performed for the removal of a port-wine stain or hemangioma (only on the face) 3. Treatment provided for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from 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 and is covered. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $45.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $45.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per 2 Years |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
YES | No Charge after deductible |
No Charge after deductible |
| Skilled Nursing Facility
Limit: 60.0 Days per Year 1. The admission must be within seven days of release from an inpatient Hospital stay; 2. The Skilled Nursing Facility services are of a temporary nature and increase ability to function. |
YES | No Charge after deductible |
No Charge after deductible |
| Specialist Visit
|
YES | $100.00 |
No Charge after deductible |
| Specialty Drugs
Requires Prior Approval from Health Advantage. |
YES | $5,000.00 |
100.00% |
| Specialty Drugs Tier 2
Requires Prior Approval from Health Advantage. |
YES | $5,000.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | $45.00 |
No Charge after deductible |
| Transplant
|
YES | No Charge after deductible |
No Charge after deductible |
| Treatment for Temporomandibular Joint Disorders
|
YES | No Charge after deductible |
No Charge after deductible |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
No Charge after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| Well Child Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
No Charge after deductible |
HA Bronze Suitcase Health Insurance Plan Variant 13262AR0230006-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.6478448958917521 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| 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, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.9998 |
| First Tier Utilization | 100% |
| Formulary ID | ARF005 |
| Formulary URL | URL |
| HIOS Product ID | 13262AR023 |
| Import Date | 2023-09-11 20:01:51 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 13262 |
| Issuer Marketplace Marketing Name | Health Advantage |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | ARN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Care |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Benefit Reduction |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 13262AR0230006-03 |
| Plan Level Exclusions | No |
| Plan Marketing Name | HA Bronze Suitcase |
| Plan Type | POS |
| Plan Variant Marketing Name | HA Bronze Suitcase |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $9,300 |
| SBC Scenario, Having a Baby, Limit | $40 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $7,300 |
| SBC Scenario, Having Diabetes, Limit | $60 |
| 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 | $1,900 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ARS001 |
| Source Name | SERFF |
| Plan ID | 13262AR0230006 |
| State Code | AR |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $18500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $9250 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $9,250 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $27750 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $13875 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $13,875 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9250 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,250 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $27750 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $13875 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $13,875 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of HA Bronze Suitcase Health Insurance Plan, 13262AR0230006
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about HA Bronze Suitcase, 13262AR0230006 Health Insurance Plan, 13262AR0230006
-
Does HA Bronze Suitcase Health Insurance Plan, 13262AR0230006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (13262AR0230006) Health Insurance Plan, Variant (13262AR0230006-03) offer Disease Management Programs?
Does (13262AR0230006) Health Insurance Plan, Variant (13262AR0230006-03) have Out Of Country Coverage?
Does (13262AR0230006) Health Insurance Plan, Variant (13262AR0230006-03) have Out of Service Area Coverage?
Does (13262AR0230006) Health Insurance Plan, Variant (13262AR0230006-03) offer Disease Management Programs?
Does HA Bronze Suitcase Health Insurance Plan, Variant (13262AR0230006-03) offer Disease Management Programs for Asthma?
Does HA Bronze Suitcase Health Insurance Plan, Variant (13262AR0230006-03) offer Disease Management Programs for Heart disease?
Does HA Bronze Suitcase Health Insurance Plan, Variant (13262AR0230006-03) offer Disease Management Programs for Depression?
Does HA Bronze Suitcase Health Insurance Plan, Variant (13262AR0230006-03) offer Disease Management Programs for Diabetes?
Does HA Bronze Suitcase Health Insurance Plan, Variant (13262AR0230006-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does HA Bronze Suitcase Health Insurance Plan, Variant (13262AR0230006-03) offer Disease Management Programs for Low back pain?
Does HA Bronze Suitcase Health Insurance Plan, Variant (13262AR0230006-03) offer Disease Management Programs for Pregnancy?
Does HA Bronze Suitcase Health Insurance Plan, Variant (13262AR0230006-03) offer Disease Management Programs for Weight loss programs?
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