AultCare Gold 2500 No Pediatric Dental - 28162OH0090051 Health Insurance Plan
AultCare Insurance Company health insurance plan with the Plan ID 28162OH0090051. The plan is called AultCare Gold 2500 No Pediatric Dental.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.87% (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 18.13% 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 | 28162OH0090051 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Ohio | ||||||||||||||||||
| Health Insurance Issuer | AultCare Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 28162OH0090051-00 | ||||||||||||||||||
| Provider Network(s) | ['OHN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Tue, 17 Aug 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
AultCare Gold 2500 No Pediatric Dental Health Insurance Plan Variant 28162OH0090051-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.818709053 |
| 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 Gold Off Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| First Tier Utilization | 100% |
| Formulary ID | OHF002 |
| Formulary URL | URL |
| HIOS Product ID | 28162OH009 |
| HSA/HRA Employer Contribution | No |
| Import Date | 8/17/2021 20:00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 28162 |
| Issuer Marketplace Marketing Name | AultCare Insurance Company |
| Market Coverage | SHOP (Small Group) |
| 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 | OHN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Generally, we may pay for limited Emergency Services that are necessary when You are traveling out of the USA, unless you are expressly traveling on business on behalf of Your Employer. We will consider each Claim carefully. We will not pay for Services when You go to another Country to obtain medical care. We do not pay for air transport or medical evacuation. We recommend that You obtain separate medical travel and evacuation insurance if You Plan to travel out of the USA. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Out of Service Area coverage from a network provider would be provided according to the plan benefits. Out of Service Area coverage from a Non-Network provider would be covered at the Non-Network plan benefits and the member would be responsible for any amounts exceeding plan limitations. |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 28162OH0090051-00 |
| Plan Marketing Name | AultCare Gold 2500 No Pediatric Dental |
| Plan Type | PPO |
| Plan Variant Marketing Name | AultCare Gold 2500 No Pediatric 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 | $2,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $2,500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OHS002 |
| Source Name | SERFF |
| Plan ID | 28162OH0090051 |
| State Code | OH |
| 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 | $5000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $15000 per group |
| 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 | $7,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $5000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $2,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $52200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $52200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $26,100 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of AultCare Gold 2500 No Pediatric Dental Health Insurance Plan, 28162OH0090051
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about AultCare Gold 2500 No Pediatric Dental, 28162OH0090051 Health Insurance Plan, 28162OH0090051
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Does AultCare Gold 2500 No Pediatric Dental Health Insurance Plan, 28162OH0090051 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (28162OH0090051) Health Insurance Plan, Variant (28162OH0090051-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does (28162OH0090051) Health Insurance Plan, Variant (28162OH0090051-00) have Out Of Country Coverage?
Yes. Details: Generally, we may pay for limited Emergency Services that are necessary when You are traveling out of the USA, unless you are expressly traveling on business on behalf of Your Employer. We will consider each Claim carefully. We will not pay for Services when You go to another Country to obtain medical care. We do not pay for air transport or medical evacuation. We recommend that You obtain separate medical travel and evacuation insurance if You Plan to travel out of the USA.
Does (28162OH0090051) Health Insurance Plan, Variant (28162OH0090051-00) have Out of Service Area Coverage?
Yes. Details: Out of Service Area coverage from a network provider would be provided according to the plan benefits. Out of Service Area coverage from a Non-Network provider would be covered at the Non-Network plan benefits and the member would be responsible for any amounts exceeding plan limitations.
Does (28162OH0090051) Health Insurance Plan, Variant (28162OH0090051-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does AultCare Gold 2500 No Pediatric Dental Health Insurance Plan, Variant (28162OH0090051-00) offer Disease Management Programs for Asthma?
Yes, the AultCare Gold 2500 No Pediatric Dental Health Insurance Plan Variant
28162OH0090051-00 offers Disease
Management Program for Asthma.
Does AultCare Gold 2500 No Pediatric Dental Health Insurance Plan, Variant (28162OH0090051-00) offer Disease Management Programs for Heart disease?
Yes, the AultCare Gold 2500 No Pediatric Dental Health Insurance Plan Variant
28162OH0090051-00 offers Disease
Management Program for Heart disease.
Does AultCare Gold 2500 No Pediatric Dental Health Insurance Plan, Variant (28162OH0090051-00) offer Disease Management Programs for Depression?
Yes, the AultCare Gold 2500 No Pediatric Dental Health Insurance Plan Variant
28162OH0090051-00 offers Disease
Management Program for Depression.
Does AultCare Gold 2500 No Pediatric Dental Health Insurance Plan, Variant (28162OH0090051-00) offer Disease Management Programs for Diabetes?
Yes, the AultCare Gold 2500 No Pediatric Dental Health Insurance Plan Variant
28162OH0090051-00 offers Disease
Management Program for Diabetes.
Does AultCare Gold 2500 No Pediatric Dental Health Insurance Plan, Variant (28162OH0090051-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the AultCare Gold 2500 No Pediatric Dental Health Insurance Plan Variant
28162OH0090051-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does AultCare Gold 2500 No Pediatric Dental Health Insurance Plan, Variant (28162OH0090051-00) offer Disease Management Programs for Low back pain?
Yes, the AultCare Gold 2500 No Pediatric Dental Health Insurance Plan Variant
28162OH0090051-00 offers Disease
Management Program for Low back pain.
Does AultCare Gold 2500 No Pediatric Dental Health Insurance Plan, Variant (28162OH0090051-00) offer Disease Management Programs for Pregnancy?
Yes, the AultCare Gold 2500 No Pediatric Dental Health Insurance Plan Variant
28162OH0090051-00 offers Disease
Management Program for Pregnancy.
Does AultCare Gold 2500 No Pediatric Dental Health Insurance Plan, Variant (28162OH0090051-00) offer Disease Management Programs for Weight loss programs?
Yes, the AultCare Gold 2500 No Pediatric Dental Health Insurance Plan Variant
28162OH0090051-00 offers Disease
Management Program for Weight loss programs.
Disclaimer: This is based on the import(Date: Tue, 30 Apr 2024 06:06 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