Silver AH - 75293AR1200004 Health Insurance Plan
USAble Mutual Insurance Company health insurance plan with the Plan ID 75293AR1200004. The plan is called Silver AH.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.07% (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 12.93% 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 | 75293AR1200004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Arkansas | ||||||||||||||||||
| Health Insurance Issuer | USAble Mutual Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 75293AR1200004-05 | ||||||||||||||||||
| Provider Network(s) | TRUE-BLUE-PPO 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 - 75293AR1200004-00 Standard On Exchange Plan - 75293AR1200004-01 Open to Indians below 300% FPL - 75293AR1200004-02 Open to Indians above 300% FPL - 75293AR1200004-03 73% AV Silver Plan - 75293AR1200004-04 |
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| Last Plan Update Date | Thu, 10 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Silver AH Health Insurance Plan, 75293AR1200004-05
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
SOB includes 'allergy services.' |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Applied Behavior Analysis Based Therapies
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge 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 | $5.00 Copay after deductible |
100.00% |
| Cochlear Implants
One cochlear implant per ear per Covered Person per lifetime |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Craniofacial Surgery
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services: 75293AR1200004-01-30% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200004-02-No charge for in-network and out-of-network services; 75293AR1200004-03-30% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200004-04-No charge after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200004-05-No charge after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200004-06-No charge 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 the Company. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Dental Anesthesia
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Diabetes Education
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | $250.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | $240.00 Copay after deductible |
$240.00 Copay 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 |
50.00% Coinsurance after deductible |
| Gastric Electrical Stimulation
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Gender Affirming Care
|
YES | No Charge after deductible |
100.00% |
| Generic Drugs
Mail Order cost: 75293AR1200004-01- $200 Copay in-network, 75293AR1200004-03- $200 Copay in-network, 75293AR1200004-04- $200 Copay in-network, 75293AR1200004-05- $10 Copay in-network, and 75293AR1200004-06- $9.40 Copay in-network. |
YES | $5.00 |
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 | $5.00 Copay after deductible |
100.00% |
| Hearing Aids
Coverage is limited to $1400/hearing aid |
YES | 80.00% |
80.00% |
| 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 | No Charge 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, the Company 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 the Company as a Provider. This benefit is subject to the Deductible, Copayment and Coinsurance specified in the Schedule of Benefits. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | $5.00 |
50.00% Coinsurance after deductible |
| Infertility Treatment
4 oocyte retrievals or 2 live births from separate pregnancies |
YES | No Charge after deductible |
100.00% |
| Infusion Therapy
Home infusion therapy. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Inherited Metabolic Disorder - PKU
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
Requires prior notification to the Company. |
YES | $240.00 Copay per Day after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | $5.00 |
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
Requires prior notification to the Company. |
YES | $240.00 Copay per Day after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
Cost Sharing does NOT apply to screenings. The cost sharing that displays applies to outpatient evaluation, consultation, and psychotherapy office visits only. All other outpatient services and procedures provided in an office or outpatient facility may be subject to additional cost sharing. Please refer to plan policy documents for detailed information. |
YES | $5.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
Mail Order cost: 75293AR1200004-01- $4000 Copay in-network, 75293AR1200004-03- $4000 Copay in-network, 75293AR1200004-04- $4000 Copay in-network, 75293AR1200004-05- $200 Copay in-network, and 75293AR1200004-06- $18.80 Copay in-network. |
YES | $100.00 |
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 the Company. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Off Label Prescription Drugs
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $5.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $5.00 Copay 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 | $5.00 Copay after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $5.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
Mail Order cost: 75293AR1200004-01- $2000 Copay in-network, 75293AR1200004-03- $2000 Copay in-network, 75293AR1200004-04- $2000 Copay in-network, 75293AR1200004-05- $50 Copay in-network, and 75293AR1200004-06- $9.40 Copay in-network. |
YES | $25.00 |
100.00% |
| Prenatal and Postnatal Care
Requires Prior Notification to the Company. Coverage for routine ultrasound is limited to 1. |
YES | No Charge after deductible |
50.00% Coinsurance 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
|
YES | $5.00 Copay after deductible |
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 | No Charge after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | No Charge 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. |
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 | $5.00 |
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 | $5.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| 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 |
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 | $240.00 Copay per Day after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $5.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Specialty Drugs
Requires prior approval from the Company. |
YES | $2,415.00 |
100.00% |
| Specialty Drugs Tier 2
Requires prior approval from the Company. |
YES | $2,415.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Requires prior notification to the Company. |
YES | $240.00 Copay per Day after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | $5.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Transplant
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
|
YES | $5.00 Copay after deductible |
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 | $5.00 |
50.00% Coinsurance after deductible |
Silver AH Health Insurance Plan Variant 75293AR1200004-05 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.870685351297413 |
| 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 | 87% AV Level Silver 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 | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Drug EHB Deductible, Out of Network, Individual | $0 |
| 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 | 0.9994 |
| First Tier Utilization | 100% |
| Formulary ID | ARF001 |
| Formulary URL | URL |
| HIOS Product ID | 75293AR120 |
| Import Date | 2024-10-10 20:01:47 |
| 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 ID | 75293 |
| Issuer Marketplace Marketing Name | Arkansas Blue Cross and Blue Shield |
| 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 | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $3530 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $1765 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,765 |
| Medical EHB Deductible, Out of Network, Family Per Group | $16800 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $8400 per person |
| Medical EHB Deductible, Out of Network, Individual | $8,400 |
| Metal Level | Silver |
| 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 | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 75293AR1200004-05 |
| Plan Level Exclusions | No |
| Plan Marketing Name | Silver AH |
| Plan Type | PPO |
| Plan Variant Marketing Name | Silver AH |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $20 |
| SBC Scenario, Having a Baby, Deductible | $1,800 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $1,800 |
| SBC Scenario, Having Diabetes, Limit | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $800 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ARS001 |
| Source Name | SERFF |
| Plan ID | 75293AR1200004 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $4830 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $2415 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $2,415 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $19200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $9600 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $9,600 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Silver AH Health Insurance Plan, 75293AR1200004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Silver AH, 75293AR1200004 Health Insurance Plan, 75293AR1200004
-
Does Silver AH Health Insurance Plan, 75293AR1200004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (75293AR1200004) Health Insurance Plan, Variant (75293AR1200004-05) offer Disease Management Programs?
Does (75293AR1200004) Health Insurance Plan, Variant (75293AR1200004-05) have Out Of Country Coverage?
Does (75293AR1200004) Health Insurance Plan, Variant (75293AR1200004-05) have Out of Service Area Coverage?
Does (75293AR1200004) Health Insurance Plan, Variant (75293AR1200004-05) offer Disease Management Programs?
Does Silver AH Health Insurance Plan, Variant (75293AR1200004-05) offer Disease Management Programs for Asthma?
Does Silver AH Health Insurance Plan, Variant (75293AR1200004-05) offer Disease Management Programs for Heart disease?
Does Silver AH Health Insurance Plan, Variant (75293AR1200004-05) offer Disease Management Programs for Depression?
Does Silver AH Health Insurance Plan, Variant (75293AR1200004-05) offer Disease Management Programs for Diabetes?
Does Silver AH Health Insurance Plan, Variant (75293AR1200004-05) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Silver AH Health Insurance Plan, Variant (75293AR1200004-05) offer Disease Management Programs for Low back pain?
Does Silver AH Health Insurance Plan, Variant (75293AR1200004-05) offer Disease Management Programs for Pregnancy?
Does Silver AH Health Insurance Plan, Variant (75293AR1200004-05) 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