UHC Silver Standard - 69842LA0240017 Health Insurance Plan
UnitedHealthcare Insurance Company health insurance plan with the Plan ID 69842LA0240017. The plan is called UHC Silver Standard.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.00% (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 27.00% 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 | 69842LA0240017 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Louisiana | ||||||||||||||||||
| Health Insurance Issuer | UnitedHealthcare Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 69842LA0240017-04 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED NETWORK | ||||||||||||||||||
| 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 - 69842LA0240017-00 Standard On Exchange Plan - 69842LA0240017-01 Open to Indians below 300% FPL - 69842LA0240017-02 Open to Indians above 300% FPL - 69842LA0240017-03 73% AV Silver Plan - 69842LA0240017-04 |
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| Last Plan Update Date | Sat, 16 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of UHC Silver Standard Health Insurance Plan, 69842LA0240017-04
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 40% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $80.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 40% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 40% Coinsurance after deductible |
100.00% |
| Chiropractic Care
|
YES | 40% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services follow inpatient physician/surgeon fees |
YES | 40% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | No Charge |
100.00% |
| Diabetes Education
|
YES | 40% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 40% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 40% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 40.00% Coinsurance after deductible |
40% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 40% Coinsurance after deductible |
40% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 40% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Limit: 30.0 Days per Month Lowest cost shares are available at preferred retail pharmacies and home delivery. See SBC for cost shares at other retail pharmacies and for non-preferred generics. 90-day supplies are available through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. See SBC for non-preferred generic cost shares. Generic medications are available in 90-day supplies through home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | $20.00 |
100.00% |
| Habilitation Services
Visit limits do not apply for physical therapy, occupational therapy, and speech therapy. |
YES | $40.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Benefits are limited to one hearing aid, per hearing impaired ear, in a thirty-six (36) month period. |
YES | 40% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | 40% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 40% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 40% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 40% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Limit: 18.0 Visit(s) per Year Limited to 18 Presumptive Drug Tests per year. Limited to 18 Definitive Drug Tests per year. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 40% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $40.00 |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Days per Month Non-preferred brand medications are available in 90-day supplies through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. Non-preferred brand medications are available in 90-day supplies through home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | $80.00 Copay after deductible |
100.00% |
| Nutritional Counseling
|
YES | 40% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Coverage is for medically necessary orthodontia only. |
YES | 50% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 40% Coinsurance after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Visit limits do not apply for physical therapy, occupational therapy, and speech therapy. |
YES | $40.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Days per Month Preferred brand medications are available in 90-day supplies through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. Preferred brand medications are available in 90-day supplies through home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | $40.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Cost sharing for Virtual Primary Care matches in-person office visit. See SBC for additional cost share details. |
YES | $40.00 |
100.00% |
| Private-Duty Nursing
Limit: 22.0 Visit(s) per Year Exclusions: Inpatient Private Duty Nursing Service is not covered. Private Duty Nursing services covered as a part of the Home Health Care benefit. |
YES | 40% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 40% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 40% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 40% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | $40.00 |
100.00% |
| Rehabilitative Speech Therapy
|
YES | $40.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $80.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Days per Month Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply. |
YES | $125.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $40.00 |
100.00% |
| Transplant
|
YES | 40% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $60.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 40.00% Coinsurance after deductible |
100.00% |
UHC Silver-E Standard Health Insurance Plan Variant 69842LA0240017-04 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.730035409364652 |
| 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 | 73% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Design 2 |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | LAF008 |
| Formulary URL | URL |
| HIOS Product ID | 69842LA024 |
| Import Date | 2023-12-16 01:02:09 |
| 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 | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 69842 |
| Issuer Marketplace Marketing Name | UnitedHealthcare |
| 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 | LAN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 69842LA0240017-04 |
| Plan Marketing Name | UHC Silver Standard |
| Plan Type | EPO |
| Plan Variant Marketing Name | UHC Silver-E Standard |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $5,700 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $300 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,200 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | LAS001 |
| Source Name | HIOS |
| Plan ID | 69842LA0240017 |
| State Code | LA |
| 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 | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $11400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5700 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,700 |
| 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 | $14400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,200 |
| 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 | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of UHC Silver Standard Health Insurance Plan, 69842LA0240017
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about UHC Silver Standard, 69842LA0240017 Health Insurance Plan, 69842LA0240017
-
Does UHC Silver Standard Health Insurance Plan, 69842LA0240017 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (69842LA0240017) Health Insurance Plan, Variant (69842LA0240017-04) have Out Of Country Coverage?
Does (69842LA0240017) Health Insurance Plan, Variant (69842LA0240017-04) have Out of Service Area Coverage?
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