Celtic Insurance Company health insurance plan with the Plan ID 62141AR0100013. The plan is called Premier Silver + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 73.93% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 26.07% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.93% (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 26.07% 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 | 62141AR0100013 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Arkansas | ||||||||||||||||||
Health Insurance Issuer | Celtic Insurance Company | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 62141AR0100013-04 | ||||||||||||||||||
Provider Network(s) | ['ARN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 01 Oct 2024 06:11 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 62141AR0100013-00 Standard On Exchange Plan - 62141AR0100013-01 Open to Indians below 300% FPL - 62141AR0100013-02 Open to Indians above 300% FPL - 62141AR0100013-03 73% AV Silver Plan - 62141AR0100013-04 |
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Last Plan Update Date | Wed, 14 Dec 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 01 Oct 2024 06:11 GMT |
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 | No Charge after deductible |
60.00% Coinsurance after deductible |
Acupuncture
|
NO | ||
Allergy Testing
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $45.00 |
60.00% |
Applied Behavior Analysis Based Therapies
Person with diagnosis of serious mental or physical condition; Person certified by a PCP to have significant behavioral problem. Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
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 Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Chemotherapy
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Chiropractic Care
Limit: 30.0 Visit(s) per Year Combined 30 visit limit per year for Chiropractic Care, PT, OT and ST. |
YES | $45.00 |
60.00% |
Cochlear Implants
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Cosmetic Surgery
|
NO | ||
Craniofacial Surgery
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
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 | No Charge after deductible |
60.00% Coinsurance after deductible |
Dental Anesthesia
Person under 7 requiring dental treatment w/o delay. Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Dental Check-Up for Children
|
NO | ||
Diabetes Care Management
Covered based on medical necessity. Prior authorization may be required - please contact the number listed on your ID card. |
YES | $45.00 |
60.00% |
Diabetes Education
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $45.00 |
60.00% |
Dialysis
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Durable Medical Equipment
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
Emergency Transportation/Ambulance
Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | No Charge after deductible |
No Charge after deductible |
Eye Glasses for Adults
Limit: 1.0 Item(s) per Year Covered up to $130 |
YES | No Charge |
No Charge |
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 |
100.00% |
Gastric Electrical Stimulation
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Gender Affirming Care
|
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Generic Drugs
Prior authorization may be required - please contact the number listed on your ID card. Most Ambetter Plans offer Preferred Generic Drugs at $5 or less. Please see plan's Summary of Benefits and Coverage (SBC) or policy document for Preferred Generic and Generic prescription drug cost. |
YES | $13.80 |
100.00% |
Habilitation Services
Limit: 30.0 Visit(s) per Year 30 visits per year for outpatient habilatative services. 180 visits per year for developmental services. Prior authorization may be required - please contact the number on your ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Hearing Aids
Limit: 2.0 Item(s) per 3 Years 1 pair every 3 years. Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge |
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 | No Charge after deductible |
60.00% Coinsurance after deductible |
Hospice Services
Limit: 180.0 Days per Year Benefits for hospice inpatient, home or outpatient care are available to a terminally ill covered person for one continuous period up to 180 days in a covered person's lifetime. Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Imaging (CT/PET Scans, MRIs)
Prior authorization may be required - please contact the number listed on your ID card. Cost share is based on place of service. |
YES | No Charge after deductible |
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 | No Charge after deductible |
60.00% Coinsurance after deductible |
Infusion Therapy
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Inherited Metabolic Disorder - PKU
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
60.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
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 after deductible |
60.00% Coinsurance after deductible |
Laboratory Outpatient and Professional Services
Prior authorization may be required - please contact the number listed on your ID card. Cost share is based on place of service. |
YES | No Charge after deductible |
60.00% |
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
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 | No Charge after deductible |
No Charge after deductible |
Mental/Behavioral Health Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
Mental/Behavioral Health ER Physician Fee
|
YES | No Charge after deductible |
No Charge after deductible |
Mental/Behavioral Health Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
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. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Mental/Behavioral Health Outpatient Services
Prior authorization may be required - please contact the number listed on your ID card. (PCP and Other Practitioner visits do not require Prior Authorization) |
YES | $15.00 |
60.00% |
Mental/Behavioral Health Urgent Care
|
YES | $15.00 |
60.00% |
Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
Nutritional Counseling
When provided in conjunction with Diabetic Self-Management Training, for services needed by Members in connection with cleft palate management and for nutritional assessment programs provided in and by a Hospital. Prior authorization may be required - please contact the number listed on your id card. |
YES | $45.00 |
60.00% |
Off Label Prescription Drugs
|
YES | No Charge after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $15.00 |
60.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
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. (Including Speech. Occupational, and Physical Therapy). Combined 30 visit limit per year for PT, OT, ST and Chiropractic Care. |
YES | No Charge after deductible |
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 | No Charge after deductible |
60.00% Coinsurance after deductible |
Preferred Brand Drugs
|
YES | $50.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | $15.00 |
60.00% |
Preventative Drugs
|
YES | No Charge |
100.00% |
Preventive Care/Screening/Immunization
|
YES | No Charge |
60.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | $15.00 |
60.00% |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Radiation
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
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 | No Charge after deductible |
60.00% Coinsurance after deductible |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year 60 inpatient days/year. 30 visit limit is combined with PT, OT, speech and Chiropractic Care. Prior authorization may be required - please contact the number on your ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Combined 30 visit limit per year for PT, OT, ST and Chiropractic Care. Prior authorization may be required - please contact the number on your ID card. |
YES | No Charge after deductible |
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: Up to $38.50 |
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 |
100.00% |
Routine Foot Care
Prior authorization may be required. Covered no limit. |
YES | $45.00 |
60.00% |
Skilled Nursing Facility
Limit: 60.0 Days per Year 60 days per year in a facility. Prior authorization may be required - please contact the number listed on you ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Specialist Visit
|
YES | $45.00 |
60.00% |
Specialty Drugs
|
YES | No Charge after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Substance Abuse Disorder Outpatient Services
Prior authorization may be required - please contact the number listed on your ID card. (PCP and Other Practitioner visits do not require Prior Authorization) |
YES | $15.00 |
60.00% |
Substance Use Disorder Emergency Room
|
YES | No Charge after deductible |
No Charge after deductible |
Substance Use Disorder Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
Substance Use Disorder ER Physician Fee
|
YES | No Charge after deductible |
No Charge after deductible |
Substance Use Disorder Outpatient Other Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Substance Use Disorder Urgent Care
|
YES | $15.00 |
60.00% |
Transplant
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
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 | No Charge after deductible |
60.00% Coinsurance after deductible |
Urgent Care Centers or Facilities
|
YES | $45.00 |
60.00% |
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. Cost share is based on place of service. |
YES | No Charge after deductible |
60.00% Coinsurance after deductible |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.739288665 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | 73% AV Level Silver Plan |
Dental Only Plan | No |
Design Type | Not Applicable |
Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
EHB Percent of Total Premium | 0.9544717 |
First Tier Utilization | 100% |
Formulary ID | ARF014 |
Formulary URL | URL |
HIOS Product ID | 62141AR010 |
Import Date | 12/14/2022 20:01 |
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 | 73.93% |
Issuer ID | 62141 |
Issuer Marketplace Marketing Name | Ambetter from Arkansas Health & Wellness |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
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 | 1/1/2023 |
Plan ID (Standard Component ID with Variant) | 62141AR0100013-04 |
Plan Marketing Name | Premier Silver + Vision + Adult Dental |
Plan Type | PPO |
Plan Variant Marketing Name | Premier Silver + Vision + Adult Dental |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $20 |
SBC Scenario, Having a Baby, Deductible | $5,900 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $1,000 |
SBC Scenario, Having Diabetes, Deductible | $900 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | ARS001 |
Source Name | SERFF |
Plan ID | 62141AR0100013 |
State Code | AR |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $38500 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $19250 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $19,250 |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $28500 per group |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $14250 per person |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $14,250 |
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 | $13500 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6750 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,750 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $15000 per group |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $7500 per person |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | $7,500 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $13500 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6750 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,750 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $25000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $12500 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $12,500 |
Unique Plan Design | Yes |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 01 Oct 2024 06:11 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