AultCare Insurance Company health insurance plan with the Plan ID 28162OH0090060. The plan is called AultCare Silver 5400.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.84% (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 28.16% 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 | 28162OH0090060 | ||||||||||||||||||
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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 | 28162OH0090060-01 | ||||||||||||||||||
Provider Network(s) | ['OHN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 14 May 2024 06:16 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, 14 May 2024 06:16 GMT |
Plan Attribute | Value |
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AV Calculator Output Number | 0.71841727 |
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 On Exchange 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 | 50.00% |
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 | per group not applicable |
Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
Drug EHB Deductible, Out of Network, Individual | $0 |
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 | OHF001 |
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 | No |
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 | 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 | 15.00% |
Medical EHB Deductible, In Network (Tier 1), Family Per Group | $10800 per group |
Medical EHB Deductible, In Network (Tier 1), Family Per Person | $5400 per person |
Medical EHB Deductible, In Network (Tier 1), Individual | $5,400 |
Medical EHB Deductible, Out of Network, Family Per Group | $32400 per group |
Medical EHB Deductible, Out of Network, Family Per Person | $16200 per person |
Medical EHB Deductible, Out of Network, Individual | $16,200 |
Metal Level | Silver |
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) | 28162OH0090060-01 |
Plan Marketing Name | AultCare Silver 5400 |
Plan Type | PPO |
Plan Variant Marketing Name | AultCare Silver 5400 |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $1,080 |
SBC Scenario, Having a Baby, Copayment | $10 |
SBC Scenario, Having a Baby, Deductible | $5,400 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $940 |
SBC Scenario, Having Diabetes, Copayment | $320 |
SBC Scenario, Having Diabetes, Deductible | $1,140 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,590 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | OHS002 |
Source Name | SERFF |
Plan ID | 28162OH0090060 |
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 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
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 | $26100 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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 14 May 2024 06:16 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