Standard Gold + Vision + Adult Dental - 62141AR0100035 Health Insurance Plan

Celtic Insurance Company health insurance plan with the Plan ID 62141AR0100035. The plan is called Standard Gold + Vision + Adult Dental.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (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 21.94% 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 62141AR0100035
Health Insurance Plan Year 2025
State Arkansas
Health Insurance Issuer Celtic Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 62141AR0100035-01
Provider Network(s) 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).

Providers Arkansas 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 - 62141AR0100035-00

Standard On Exchange Plan - 62141AR0100035-01

Open to Indians below 300% FPL - 62141AR0100035-02

Open to Indians above 300% FPL - 62141AR0100035-03

Last Plan Update Date Mon, 12 Aug 2024 00:00 GMT
Last Import Date Thu, 21 Nov 2024 00:44 GMT

Benefits of Standard Gold + Vision + Adult Dental Health Insurance Plan, 62141AR0100035-01

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

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing

Prior authorization may be required - please contact the number listed on your ID card.

YES

$60.00

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

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

YES

$30.00

50.00% Coinsurance after deductible
Chemotherapy

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chiropractic Care

Limit: 30.0 Visit(s) per Year

Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

YES

$60.00

50.00% Coinsurance after deductible
Cochlear Implants
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

Prior authorization may be required - please contact the number listed on your ID card.

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

$60.00

50.00% Coinsurance after deductible
Diabetes Education

Prior authorization may be required - please contact the number listed on your ID card.

YES

$60.00

50.00% Coinsurance after deductible
Dialysis

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Durable Medical Equipment

Prior authorization may be required - please contact the number listed on your ID card.

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

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.

YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
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

No Charge
Gastric Electrical Stimulation
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Gender Affirming Care
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Generic Drugs

Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information.

YES

$15.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Year

Prior authorization may be required - please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient habilitation services; limited to 180 visits per year for developmental services.

YES

$30.00

50.00% Coinsurance after deductible
Hearing Aids

Limit: 2.0 Item(s) per 3 Years

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00%

50.00%
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

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Hospice Services

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% 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

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infusion Therapy

Prior authorization may be required - please contact the number listed on your ID card.

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)

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
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

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Mental/Behavioral Health Emergency Transportation/Ambulance

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.

YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Mental/Behavioral Health ER Physician Fee
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Other Services

Prior authorization may be required - please contact the number listed on your ID card. Note: Cost share will be waived for Behavioral Health screening services.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
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. Cost share will be waived for Behavioral Health screening services.

YES

$30.00

50.00% Coinsurance after deductible
Mental/Behavioral Health Urgent Care
YES

$30.00

50.00% Coinsurance after deductible
Non-Preferred Brand Drugs
YES

$60.00

100.00%
Nutritional Counseling
YES

$60.00

50.00% Coinsurance after deductible
Off Label Prescription Drugs
YES

$250.00

100.00%
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)

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% 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. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

YES

$30.00

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preferred Brand Drugs
YES

$30.00

100.00%
Prenatal and Postnatal Care
YES

$30.00

50.00% Coinsurance after deductible
Preventative Drugs
YES

No Charge

100.00%
Preventive Care/Screening/Immunization

Covered in accordance with ACA guidelines.

YES

0.00%

50.00%
Primary Care Visit to Treat an Injury or Illness
YES

$30.00

50.00% Coinsurance after deductible
Private-Duty Nursing
NO
Prosthetic Devices

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Radiation

Prior authorization may be required - please contact the number listed on your ID card.

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 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

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Year

60 inpatient days/year. Prior authorization may be required - please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

YES

$30.00

50.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Year

Prior authorization may be required - please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

YES

$30.00

50.00% 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 exam: Up to $38.50. 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. OON eyewear benefit: covered up to $50 for frames, lenses up to $37.50 and contact lenses up to $91.

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

No Charge
Routine Foot Care
YES

$60.00

50.00% Coinsurance after deductible
Skilled Nursing Facility

Limit: 60.0 Days per Year

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Specialist Visit
YES

$60.00

50.00% Coinsurance after deductible
Specialty Drugs
YES

$250.00

100.00%
Substance Abuse Disorder Inpatient Services

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
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. Cost share will be waived for Behavioral Health screening services.

YES

$30.00

50.00% Coinsurance after deductible
Substance Use Disorder Emergency Room
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Substance Use Disorder Emergency Transportation/Ambulance

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.

YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Substance Use Disorder ER Physician Fee
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Substance Use Disorder Outpatient Other Services

Prior authorization may be required - please contact the number listed on your ID card. Note: Cost share will be waived for Behavioral Health screening services.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Use Disorder Urgent Care
YES

$30.00

50.00% Coinsurance after deductible
Transplant

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders

Prior authorization may be required - please contact the number listed on your ID card.

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

50.00%
Well Child Care
YES

No Charge

50.00%
X-rays and Diagnostic Imaging

Prior authorization may be required - please contact the number listed on your ID card.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible

Standard Gold + Vision + Adult Dental Health Insurance Plan Variant 62141AR0100035-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7806125763529309
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 Standard Gold On Exchange Plan
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 0.965649944220338
First Tier Utilization 100%
Formulary ID ARF009
Formulary URL URL
HIOS Product ID 62141AR010
Import Date 2024-08-12 20:01:40
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 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 Gold
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 2025-01-01
Plan ID (Standard Component ID with Variant) 62141AR0100035-01
Plan Marketing Name Standard Gold + Vision + Adult Dental
Plan Type PPO
Plan Variant Marketing Name Standard Gold + Vision + Adult Dental
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,100
SBC Scenario, Having a Baby, Copayment $40
SBC Scenario, Having a Baby, Deductible $1,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $900
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
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 62141AR0100035
State Code AR
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $33000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $16500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $16,500
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $8000 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $4000 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $4,000
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 $5000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $2500 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $2,500
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $15600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7800 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,800
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $8,700
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Standard Gold + Vision + Adult Dental Health Insurance Plan, 62141AR0100035

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

Frequently Asked Questions(FAQ) about Standard Gold + Vision + Adult Dental, 62141AR0100035 Health Insurance Plan, 62141AR0100035

  • Does Standard Gold + Vision + Adult Dental Health Insurance Plan, 62141AR0100035 support Mail Ordering?

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

  • Does (62141AR0100035) Health Insurance Plan, Variant (62141AR0100035-01) offer Disease Management Programs?

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

    Does (62141AR0100035) Health Insurance Plan, Variant (62141AR0100035-01) have Out Of Country Coverage?

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

    Does (62141AR0100035) Health Insurance Plan, Variant (62141AR0100035-01) 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 (62141AR0100035) Health Insurance Plan, Variant (62141AR0100035-01) offer Disease Management Programs?

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

    Does Standard Gold + Vision + Adult Dental Health Insurance Plan, Variant (62141AR0100035-01) offer Disease Management Programs for Asthma?

    Yes, the Standard Gold + Vision + Adult Dental Health Insurance Plan Variant 62141AR0100035-01 offers Disease Management Program for Asthma.

    Does Standard Gold + Vision + Adult Dental Health Insurance Plan, Variant (62141AR0100035-01) offer Disease Management Programs for Heart disease?

    Yes, the Standard Gold + Vision + Adult Dental Health Insurance Plan Variant 62141AR0100035-01 offers Disease Management Program for Heart disease.

    Does Standard Gold + Vision + Adult Dental Health Insurance Plan, Variant (62141AR0100035-01) offer Disease Management Programs for Diabetes?

    Yes, the Standard Gold + Vision + Adult Dental Health Insurance Plan Variant 62141AR0100035-01 offers Disease Management Program for Diabetes.

    Does Standard Gold + Vision + Adult Dental Health Insurance Plan, Variant (62141AR0100035-01) offer Disease Management Programs for Pregnancy?

    Yes, the Standard Gold + Vision + Adult Dental Health Insurance Plan Variant 62141AR0100035-01 offers Disease Management Program for Pregnancy.

 

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