Ambetter Balanced Care 4 + Vision + Adult Dental - 99723MO0110014 Health Insurance Plan
Celtic Insurance Company health insurance plan with the Plan ID 99723MO0110014. The plan is called Ambetter Balanced Care 4 + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.15% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.85% 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 71.15% (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 28.85% 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 | 99723MO0110014 |
|---|---|
| Health Insurance Plan Year | 2022 |
| State | Missouri |
| Health Insurance Issuer | Celtic Insurance Company |
| Plan Formulary Description URL | Formulary URL |
| Plan Marketing Materials URL | Marketing URL |
| Last Plan Update Date | Fri, 13 Aug 2021 00:00 GMT |
| Last Import Date | Thu, 30 Nov 2023 20:12 GMT |
| Health Insurance Plan Variant | 99723MO0110014-00 |
| Available Variants of the Health Plan | Standard Off Exchange Plan - 99723MO0110014-00 Standard On Exchange Plan - 99723MO0110014-01 Open to Indians below 300% FPL - 99723MO0110014-02 Open to Indians above 300% FPL - 99723MO0110014-03 73% AV Silver Plan - 99723MO0110014-04 |
Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan Variant 99723MO0110014-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.711463153 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2022 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver Off Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 0.9675 |
| First Tier Utilization | 100% |
| Formulary ID | MOF002 |
| Formulary URL | URL |
| HIOS Product ID | 99723MO011 |
| Import Date | 8/13/2021 1:01 |
| 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 | 71.15% |
| Issuer ID | 99723 |
| Issuer Marketplace Marketing Name | Ambetter from Home State Health |
| 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 | MON001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan ID (Standard Component ID with Variant) | 99723MO0110014-00 |
| Plan Marketing Name | Ambetter Balanced Care 4 + Vision + Adult Dental |
| Plan Type | EPO |
| Plan Variant Marketing Name | Ambetter Balanced Care 4 + Vision + Adult Dental |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,200 |
| 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 | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,100 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MOS001 |
| Source Name | HIOS |
| Plan ID | 99723MO0110014 |
| State Code | MO |
| 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 | $14400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,200 |
| 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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan, 99723MO0110014
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Ambetter Balanced Care 4 + Vision + Adult Dental, 99723MO0110014 Health Insurance Plan, 99723MO0110014
-
Does Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan, 99723MO0110014 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (99723MO0110014) Health Insurance Plan, Variant (99723MO0110014-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy
Does (99723MO0110014) Health Insurance Plan, Variant (99723MO0110014-00) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (99723MO0110014) Health Insurance Plan, Variant (99723MO0110014-00) 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 (99723MO0110014) Health Insurance Plan, Variant (99723MO0110014-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy
Does Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan, Variant (99723MO0110014-00) offer Disease Management Programs for Asthma?
Yes, the Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan Variant
99723MO0110014-00 offers Disease
Management Program for Asthma.
Does Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan, Variant (99723MO0110014-00) offer Disease Management Programs for Heart disease?
Yes, the Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan Variant
99723MO0110014-00 offers Disease
Management Program for Heart disease.
Does Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan, Variant (99723MO0110014-00) offer Disease Management Programs for Diabetes?
Yes, the Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan Variant
99723MO0110014-00 offers Disease
Management Program for Diabetes.
Does Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan, Variant (99723MO0110014-00) offer Disease Management Programs for Pregnancy?
Yes, the Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan Variant
99723MO0110014-00 offers Disease
Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Thu, 30 Nov 2023 20:12 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