Octave Gold Standardized - 48772AR0010001 Health Insurance Plan
USAble HMO, Inc. health insurance plan with the Plan ID 48772AR0010001. The plan is called Octave Gold Standardized.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.02% (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 21.98% 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 | 48772AR0010001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Arkansas | ||||||||||||||||||
| Health Insurance Issuer | USAble HMO, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 48772AR0010001-00 | ||||||||||||||||||
| Provider Network(s) | USABLE-MUTUAL-CONNECT-PPO NON-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 - 48772AR0010001-00 Standard On Exchange Plan - 48772AR0010001-01 |
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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 Octave Gold Standardized Health Insurance Plan, 48772AR0010001-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
SOB includes 'allergy services.' |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Applied Behavior Analysis Based Therapies
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance 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 | $30.00 |
100.00% |
| Cochlear Implants
One cochlear implant per ear per Covered Person per lifetime |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Craniofacial Surgery
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services: 48772AR0010001-01-25% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 48772AR0010001-02-No charge for in-network and out-of-network services; 48772AR0010001-03-25% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for 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 Octave. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Anesthesia
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Diabetes Education
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Gastric Electrical Stimulation
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Gender Affirming Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Mail Order cost: 48772AR001001-01- $30 Copay in-network, and 48772AR001001-03- $30 Copay in-network |
YES | $15.00 |
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. |
YES | $30.00 |
100.00% |
| Hearing Aids
Coverage is limited to $1400/ear |
YES | 25.00% |
50.00% |
| 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 | 25.00% Coinsurance after deductible |
50.00% Coinsurance 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, Octave 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 Octave as a Provider. This benefit is subject to the Deductible, Copayment and Coinsurance specified in the Schedule of Benefits. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Home infusion therapy. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inherited Metabolic Disorder - PKU
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance 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 | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
Cost Sharing does NOT apply to screenings. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
Mail Order cost: 48772AR001001-01- $120 Copay in-network, and 48772AR001001-03- $120 Copay in-network |
YES | $60.00 |
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 Octave. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Off Label Prescription Drugs
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance 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. |
YES | $30.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
Mail Order cost: 48772AR001001-01- $60 Copay in-network, and 48772AR001001-03- $60 Copay in-network |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
Requires Prior Notification to Octave. Coverage for routine ultrasound is limited to 1. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
Limit: 1.0 Visit(s) per Year |
YES | 0.00% |
100.00% |
| Preventive Drugs
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
50.00% Coinsurance 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 | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | 25.00% Coinsurance 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 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 | 25.00% Coinsurance 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 | $30.00 |
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 | $30.00 |
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 | 25.00% Coinsurance after deductible |
50.00% Coinsurance 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 | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| Specialty Drugs
Requires Prior Approval from Octave. |
YES | $250.00 |
100.00% |
| Specialty Drugs Tier 2
Requires Prior Approval from Octave. |
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Transplant
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
|
YES | $45.00 |
50.00% Coinsurance 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 | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Octave Gold Standardized Health Insurance Plan Variant 48772AR0010001-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7801851164396751 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| 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 | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| 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 | ARF016 |
| Formulary URL | URL |
| HIOS Product ID | 48772AR001 |
| 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 | 48772 |
| Issuer Marketplace Marketing Name | Octave |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| 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) | 48772AR0010001-00 |
| Plan Level Exclusions | No |
| Plan Marketing Name | Octave Gold Standardized |
| Plan Type | POS |
| Plan Variant Marketing Name | Octave Gold Standardized |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,800 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $40 |
| SBC Scenario, Having Diabetes, Coinsurance | $400 |
| SBC Scenario, Having Diabetes, Copayment | $600 |
| SBC Scenario, Having Diabetes, Deductible | $1,500 |
| SBC Scenario, Having Diabetes, Limit | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ARS001 |
| Source Name | SERFF |
| Plan ID | 48772AR0010001 |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $6000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $3000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $3,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $22000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $11000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $11,000 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Octave Gold Standardized Health Insurance Plan, 48772AR0010001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Octave Gold Standardized, 48772AR0010001 Health Insurance Plan, 48772AR0010001
-
Does Octave Gold Standardized Health Insurance Plan, 48772AR0010001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (48772AR0010001) Health Insurance Plan, Variant (48772AR0010001-00) offer Disease Management Programs?
Does (48772AR0010001) Health Insurance Plan, Variant (48772AR0010001-00) have Out Of Country Coverage?
Does (48772AR0010001) Health Insurance Plan, Variant (48772AR0010001-00) have Out of Service Area Coverage?
Does (48772AR0010001) Health Insurance Plan, Variant (48772AR0010001-00) offer Disease Management Programs?
Does Octave Gold Standardized Health Insurance Plan, Variant (48772AR0010001-00) offer Disease Management Programs for Asthma?
Does Octave Gold Standardized Health Insurance Plan, Variant (48772AR0010001-00) offer Disease Management Programs for Heart disease?
Does Octave Gold Standardized Health Insurance Plan, Variant (48772AR0010001-00) offer Disease Management Programs for Depression?
Does Octave Gold Standardized Health Insurance Plan, Variant (48772AR0010001-00) offer Disease Management Programs for Diabetes?
Does Octave Gold Standardized Health Insurance Plan, Variant (48772AR0010001-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Octave Gold Standardized Health Insurance Plan, Variant (48772AR0010001-00) offer Disease Management Programs for Low back pain?
Does Octave Gold Standardized Health Insurance Plan, Variant (48772AR0010001-00) offer Disease Management Programs for Pregnancy?
Does Octave Gold Standardized Health Insurance Plan, Variant (48772AR0010001-00) 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