Premier Silver + Vision + Adult Dental - 76179IN0130079 Health Insurance Plan

Celtic Insurance Company health insurance plan with the Plan ID 76179IN0130079. The plan is called Premier Silver + Vision + Adult Dental.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.84% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.16% 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 72.84% (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 27.16% 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 76179IN0130079
Health Insurance Plan Year 2024
State Indiana
Health Insurance Issuer Celtic Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 76179IN0130079-00
Provider Network(s) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT).

Providers Indiana All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 76179IN0130079-00

Standard On Exchange Plan - 76179IN0130079-01

Open to Indians below 300% FPL - 76179IN0130079-02

Open to Indians above 300% FPL - 76179IN0130079-03

73% AV Silver Plan - 76179IN0130079-04

87% AV Silver Plan - 76179IN0130079-05

94% AV Silver Plan - 76179IN0130079-06

Last Plan Update Date Tue, 19 Dec 2023 00:00 GMT
Last Import Date Tue, 24 Dec 2024 06:21 GMT

Benefits of Premier Silver + Vision + Adult Dental Health Insurance Plan, 76179IN0130079-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

No Charge after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

$60.00

100.00%
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%

100.00%
Basic Dental Care - Child
NO
Chemotherapy
YES

No Charge after deductible

100.00%
Chiropractic Care

Limit: 12.0 Visit(s) per Year

YES

$60.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

No Charge after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

$60.00

100.00%
Dialysis
YES

No Charge after deductible

100.00%
Durable Medical Equipment
YES

No Charge after deductible

100.00%
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. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

YES

No Charge after deductible

No Charge after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

No Charge

100.00%
Gender Affirming Care
YES

No Charge after deductible

100.00%
Generic Drugs
YES

$3.00

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Year

Cost share is driven by provider/setting. Limited to 60 days per year (includes day rehabilitation therapy services provided on an outpatient basis). Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.Limits are combined both In and Out of Network.

YES

No Charge after deductible

100.00%
Hearing Aids

Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit.

NO
Home Health Care Services

Limit: 100.0 Visit(s) per Year

YES

No Charge after deductible

100.00%
Hospice Services

Respite is covered as part of hospice services only.

YES

No Charge after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

No Charge after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

No Charge after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network.

YES

No Charge after deductible

100.00%
Inpatient Physician and Surgical Services
YES

No Charge after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

No Charge after deductible

100.00%
Long-Term/Custodial Nursing Home Care
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%

100.00%
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

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

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

100.00%
Mental/Behavioral Health Outpatient Other Services
YES

No Charge after deductible

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

$30.00

100.00%
Mental/Behavioral Health Urgent Care
YES

$30.00

100.00%
Non-Preferred Brand Drugs
YES

No Charge after deductible

100.00%
Nutritional Counseling
YES

$60.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$30.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

No Charge after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Year

Cost share is driven by provider/setting. Coverage for Speech Therapy is limited to 20 visits per benefit period, Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to 20 visits per benefit period. These limits are combined in and out of network. Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network. Cardiac Rehabilitation limited to 36 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network when rendered in the home, Home Care Services limits apply.Pulmonary Rehabilitation limited to 20 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network. When rendered in the home, Home Care Services limits apply. When rendered as part of physical therapy, the Physical Therapy limit will apply instead of the limit indicated.

YES

No Charge after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge after deductible

100.00%
Preferred Brand Drugs
YES

$50.00

100.00%
Prenatal and Postnatal Care
YES

$30.00

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

$30.00

100.00%
Private-Duty Nursing

Limit: 82.0 Visit(s) per Year

Must be provided as part of home health care or outpatient visit. Inpatient is not covered.

YES

No Charge after deductible

100.00%
Prosthetic Devices
YES

No Charge after deductible

100.00%
Radiation
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Year

Outpatient rehabilitation limits apply. Limited to 60 combined visits per year (20 visits each for outpatient physical, speech and occupational therapy); limited to 36 visits per year for cardiac rehabilitation; limited to 20 visits per year for pulmonary rehabilitation.

YES

No Charge after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Outpatient rehabilitation limits apply. Limited to 60 combined visits per year (20 visits each for outpatient physical, speech and occupational therapy); limited to 36 visits per year for cardiac rehabilitation; limited to 20 visits per year for pulmonary rehabilitation.

YES

No Charge after deductible

100.00%
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

100.00%
Routine Eye Exam (Adult)

Limit: 1.0 Exam(s) per Year

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.

YES

No Charge

100.00%
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

No Charge

100.00%
Routine Foot Care
YES

$60.00

100.00%
Skilled Nursing Facility

Limit: 90.0 Days per Year

YES

No Charge after deductible

100.00%
Specialist Visit
YES

$60.00

100.00%
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

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

$30.00

100.00%
Substance Use Disorder Emergency Room
YES

No Charge after deductible

No Charge after deductible
Substance Use Disorder Emergency Transportation/Ambulance

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

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
YES

No Charge after deductible

100.00%
Substance Use Disorder Urgent Care
YES

$30.00

100.00%
Tier 3 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

$15.00

100.00%
Transplant

Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.

YES

No Charge after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

No Charge after deductible

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

No Charge after deductible

100.00%

Premier Silver + Vision + Adult Dental Health Insurance Plan Variant 76179IN0130079-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7284213744830992
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 Silver Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 0.9636
First Tier Utilization 100%
Formulary ID INF004
Formulary URL URL
HIOS Product ID 76179IN013
Import Date 2023-12-19 01:01:03
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 71.84%
Issuer ID 76179
Issuer Marketplace Marketing Name Ambetter from MHS
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 INN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 2024-01-01
Plan ID (Standard Component ID with Variant) 76179IN0130079-00
Plan Marketing Name Premier Silver + Vision + Adult Dental
Plan Type EPO
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 $30
SBC Scenario, Having a Baby, Deductible $8,100
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,100
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 $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID INS001
Source Name HIOS
Plan ID 76179IN0130079
State Code IN
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 $16300 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $8150 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $8,150
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $16300 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8150 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,150
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 Premier Silver + Vision + Adult Dental Health Insurance Plan, 76179IN0130079

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Premier Silver + Vision + Adult Dental, 76179IN0130079 Health Insurance Plan, 76179IN0130079

  • Does Premier Silver + Vision + Adult Dental Health Insurance Plan, 76179IN0130079 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (76179IN0130079) Health Insurance Plan, Variant (76179IN0130079-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does (76179IN0130079) Health Insurance Plan, Variant (76179IN0130079-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (76179IN0130079) Health Insurance Plan, Variant (76179IN0130079-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

    Does (76179IN0130079) Health Insurance Plan, Variant (76179IN0130079-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does Premier Silver + Vision + Adult Dental Health Insurance Plan, Variant (76179IN0130079-00) offer Disease Management Programs for Asthma?

    Yes, the Premier Silver + Vision + Adult Dental Health Insurance Plan Variant 76179IN0130079-00 offers Disease Management Program for Asthma.

    Does Premier Silver + Vision + Adult Dental Health Insurance Plan, Variant (76179IN0130079-00) offer Disease Management Programs for Heart disease?

    Yes, the Premier Silver + Vision + Adult Dental Health Insurance Plan Variant 76179IN0130079-00 offers Disease Management Program for Heart disease.

    Does Premier Silver + Vision + Adult Dental Health Insurance Plan, Variant (76179IN0130079-00) offer Disease Management Programs for Diabetes?

    Yes, the Premier Silver + Vision + Adult Dental Health Insurance Plan Variant 76179IN0130079-00 offers Disease Management Program for Diabetes.

    Does Premier Silver + Vision + Adult Dental Health Insurance Plan, Variant (76179IN0130079-00) offer Disease Management Programs for Pregnancy?

    Yes, the Premier Silver + Vision + Adult Dental Health Insurance Plan Variant 76179IN0130079-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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