HMO Louisiana, Inc. health insurance plan with the Plan ID 19636LA0240024. The plan is called Blue Connect Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan (L).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.01% (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 29.99% 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 | 19636LA0240024 | ||||||||||||||||||
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Health Insurance Plan Year | 2025 | ||||||||||||||||||
State | Louisiana | ||||||||||||||||||
Health Insurance Issuer | HMO Louisiana, Inc. | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 19636LA0240024-00 | ||||||||||||||||||
Provider Network(s) | NOT-APPLICABLE | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 19636LA0240024-00 Standard On Exchange Plan - 19636LA0240024-01 Open to Indians below 300% FPL - 19636LA0240024-02 Open to Indians above 300% FPL - 19636LA0240024-03 73% AV Silver Plan - 19636LA0240024-04 |
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Last Plan Update Date | Wed, 11 Sep 2024 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 10 Dec 2024 06:32 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
Dental Care and Treatment including Surgery and dental appliances required to correct Accidental Injuries of the jaws, cheeks, lips, tongue, roof or floor of mouth, and of sound natural teeth. (For the purposes of this section, sound natural teeth include those which are capped, crowned or attached by way of a crown or cap to a bridge. Sound natural teeth may have fillings or a root canal.) |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Attention Deficit Disorder
|
YES | $80.00 |
60.00% Coinsurance after deductible |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
Limitations, including dollar limits, may apply. Subject to Dental deductible, if applicable. Limitations may apply. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Chemotherapy
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Chiropractic Care
|
YES | $40.00 |
60.00% Coinsurance after deductible |
Clinical Trials
Exclusions: The following services are not covered: a. Non-healthcare services provided as part of the clinical trial; b. Costs for managing research data associated with the clinical trial; c. Investigational drugs or devices; and/or d. Services, treatment or supplies not otherwise covered under this Benefit Plan. |
YES | $80.00 |
60.00% Coinsurance after deductible |
Congenital Anomaly, including Cleft Lip/Palate
Cleft Lip and Cleft Palate Services include but not limited to: 1. Oral and facial Surgery, surgical management, and follow-up care. 2. Prosthetic treatment, such as obturators, speech appliances, and feeding appliances. 3. Orthodontic treatment and management. 4. Preventive and restorative dentistry to ensure good health and adequate dental structures for orthodontic treatment or prosthetic management or therapy. 5. Speech-language evaluation and therapy. 6. Audiological assessments and amplification devices. 7. Otolaryngology treatment and management. 8. Psychological assessment and counseling. 9. Genetic assessment and counseling for patient and parents. Includes benefits for secondary conditions and treatment attributable to the primary medical condition of either cleft lip and cleft palate. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Cosmetic Surgery
Unless required for a Congenital Anomaly. |
NO | ||
Delivery and All Inpatient Services for Maternity Care
The Member must pay applicable Copayment, Deductible Amount and/or Coinsurance. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Dental Anesthesia
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months Limitations may apply. Subject to Dental deductible, if applicable. |
YES | No Charge |
No Charge |
Diabetes Care Management
Diabetes coverage is available for the equipment, supplies, and Outpatient self-treatment training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin using diabetes if prescribed by a Member?s Physician. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Diabetes Education
Coverage is available for self-management training and education, dietician visits and for the equipment and necessary available for self-management training and education, dietician visits and for the equipment and necessary supplies for the training, if prescribed by the Member?s Physician. Coverage is available for the equipment, supplies, and Outpatient self-treatment training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin using diabetes if prescribed by the Member?s Physician. The program must be determined to be medically necessary by a physician and provided by a licensed health care professional and shall comply with the National standard for diabetes self-management education program as developed by the ADA. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Dialysis
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Durable Medical Equipment
Exclusions: Exclusions are but not limited to: hairpieces, wigs, hair growth, and/or hair implants; Personal comfort, personal hygiene and convenience items including, but not limited to, air conditioners, humidifiers, personal fitness equipment, or alterations to a Member?s home or vehicle. Limitations in connection with Durable Medical Equipment are but not limited to: (1) There is no coverage during rental of Durable Medical Equipment for repair, adjustment, or replacement of components and accessories necessary for the effective functioning and maintenance of covered equipment as this is the responsibility of the Durable Medical Equipment supplier. (2) There is no coverage for equipment where a commonly available supply or appliance can substitute to effectively serve the same purpose. (3) There is no coverage for the repair or replacement of equipment lost or damaged due to neglect or misuse. (4) Reasonable quantity limits on Durable Medical Equipment items and supplies will be determined by Us. 2. Orthotic Devices, Prosthetic Appliances and Devices (non-limb) and Prosthetic Appliances and Devices and Prosthetic Services of the Limb Limitations: a. There is no coverage for fitting, or adjustments as this is, included in the Allowable Charge b. Repair or replacement is covered only within a reasonable time period from the date of purchase subject to the expected lifetime of the device. We will determine this time period. Repair or replacement of the device will not be covered when provided under warranty. c. When Orthotic Devices are approved by Us, Benefits for standard devices will be provided toward any deluxe device. (1) Deluxe devices or deluxe features and functionalities of devices are those: (a) that do not serve a medical purpose; (b) that are not required to complete daily living activities; (c) that are solely for the Member?s comfort or convenience; or (d) that are not determined by Us to be Medically Necessary. (2) Regardless of Claims of Medical Necessity, deluxe devices and deluxe features and functionalities of devices that are not approved by Us are not covered d. No Orthotics Benefits are available for supportive devices for the foot, except when used in the treatment of diabetic foot disease. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Emergency Room Services
The ER copayment is waived if the visit results in an Inpatient Admission. |
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
Exclusions: No benefits are available if transportation is provided for the Member's comfort or convenience, or when a hospital transports members between parts of its own campus. Emergency Transportation/ Ambulance Includes but not limited to: To or from the nearest Hospital (when medically necessary); Benefits for air ambulance servcies are available only if this type of ambulance service is requested by policing or medical authorities at the site in an emergency situation or if the member is in a location that cannot be reached for a ground ambulance; |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year Pediatric selection of eyeglass frames or if a member chooses a Non-Selection frame he/she will pay the difference in retail price between the Selection and the Non-Selection frame. Prescription Contact Lenses may be selected in lieu of eyeglasses from the Pediatric Selection of Contact Lenses up to a maximum of 2 pairs of disposable or 2 pairs of planned replacement Contact Lenses. If a member chooses Non-Selection Contact Lenses he/she will pay the difference in retail price between the Selection and the Non-Selection contact lenses. Evaluation, fitting and follow-up care up to 1 visit are included when Prescription Contact Lenses are selected in lieu of eyeglasses. |
YES | No Charge |
100.00% |
Gender Affirming Care
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Generic Drugs
Exclusions: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions. Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. All pharmacy plans have preventive drugs per USPSTF for $0. For 2-tier pharmacy plans, additional selected generic preventive care drugs in certain classes cost $0. For 3-tier and 4-tier pharmacy plans, additional selected drugs in certain classes used to treat selected chronic conditions cost $0. |
YES | $20.00 |
$20.00 |
Habilitation Services
Exclusions: Other exclusions include but not limited to: Visual therapy; lifestyle/habit changing clinics and/or programs; recreational therapy; primarily to enhance athletic abilities; and/or inpatient pain rehabilitation and inpatient pain control programs An Inpatient rehabilitation Admission must begin within seventy-two (72) hours following the discharge from an Inpatient Hospital Admission for the same or similar condition. Day Rehabilitation Programs for Rehabilitative Care may be Authorized in place of Inpatient stays for rehabilitation. Day Rehabilitation Programs must begin within seventy-two (72) hours following discharge from an Inpatient Admission for the same or similar condition. Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings |
YES | $40.00 |
60.00% Coinsurance after deductible |
Hearing Aids
Limit: 1.0 Item(s) per 3 Years Exclusions: Certain exclusion apply - Please see the contract book. Benefits are available for hearing aids for covered Members when obtained from a Network Provider or another Provider approved by Us. This Benefit is limited to one hearing aid, per ear, in a thirty-six (36) month period. The hearing aid must be fitted and dispensed by a licensed audiologist or licensed hearing aid specialist or hearing aid dealer following the medical clearance of a Physician and an audiological evaluation medically appropriate to the patient. 1 hearing aid per ear every 3 years; hearing aids or for examinations for the prescribing or fitting of hearing aids. Benefits are available for hearing aids for covered Members when obtained from a Network Provider or another Provider approved by Us. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Home Health Care Services
Home Health Care services provided to a Member in lieu of an Inpatient Hospital Admission are covered; must obtain authorization. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Hospice Services
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Imaging (CT/PET Scans, MRIs)
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Inherited Metabolic Disorder - PKU
Exclusions: Exclusions are but not limited to: food or food supplements, formulas and medical foods, including those used for gastric tube feedings. Low Protein Food Products shall not include natural foods that are naturally low in protein. Benefits for Low Protein Food Products are limited to the treatment of the following diseases: Phenylketonuria (PKU); Maple Syrup Urine Disease (MSUD); Methylmalonic Acidemia (MMA); Isovaleric Acidemia (IVA); Propionic Acidemia; Glutaric Acidemia; Urea Cycle Defects; Tyrosinemia. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Inpatient Hospital Services (e.g., Hospital Stay)
Inpatient Bed, Board and General Nursing Services include but not limited to: 1. Hospital room and board and general nursing services. 2. In a Special Care Unit for a critically ill Member requiring an intensive level of care. 3. In a Skilled Nursing Facility or Unit or while receiving skilled nursing services in a Hospital, for the maximum number of days per Benefit Period shown in the Schedule of Benefits. 4. In a Residential Treatment Center for Members with Mental Disorders and Alcohol and/or Drug Abuse Benefits. B. Other Hospital Services (Inpatient and Outpatient) 1. Use of operating, delivery, recovery and treatment rooms and equipment. 2. Drugs and medicines including take-home Prescription Drugs. 3. Blood transfusions, including the cost of whole blood, blood plasma and expanders, processing charges, administrative charges, equipment and supplies. 4. Anesthesia, anesthesia supplies and anesthesia services rendered by a Hospital employee. 5. Medical and surgical supplies, casts, and splints. 6. Diagnostic Services rendered by a Hospital employee. 7. Physical Therapy provided by a Hospital employee. 8. Psychological testing when ordered by the attending Physician and performed by an employee of the hospital. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Inpatient Physician and Surgical Services
Surgical services examples include but not limited to: 1. The Allowable Charge for Inpatient and Outpatient Surgery includes all pre-operative and postoperative medical visits. 2. Multiple Surgical Procedures - When Medically Necessary multiple procedures (concurrent, successive, or other multiple surgical procedures) are performed at the same surgical setting 3. Assistant Surgeon 4. General anesthesia services are covered when requested by the operating Physician and performed by a certified registered nurse anesthetist (CRNA) or Physician, other than the operating Physician or the assistant surgeon, for covered surgical services. Inpatient Medical Services - Subject to provisions in the sections pertaining to Surgery and Pregnancy Care in this Benefit Plan, Inpatient Medical Services include: 1. Inpatient medical care visits 2. Concurrent Care 3. Consultation (as defined in this Benefit Plan) |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Laboratory Outpatient and Professional Services
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
Limitations, including dollar limits, may apply. Subject to Dental deductible, if applicable. Limitations may apply. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Mental/Behavioral Health Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Mental/Behavioral Health Outpatient Services
Exclusions: Coverage for treatment of Mental Disorders does NOT include counseling services such as career counseling, marriage counseling, divorce counseling, parental counseling and job counseling. Education services and supplies including training or re-training for a vocation, except as specifically provided in this Benefit Plan for diagnosis, testing, or treatment for remedial reading and learning disabilities, including dyslexia. Office visits are covered same as primary care physician benefit. |
YES | $40.00 |
60.00% Coinsurance after deductible |
Non-Emergency Care When Traveling Outside the U.S.
|
YES | 60.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Non-Preferred Brand Drugs
Exclusions: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions. Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. Note that for 3-tier and 4-tier plans, when a Brand-Name Drug is dispensed and a generic equivalent exists, Members must pay the Tier 1 Drug Copayment amount, plus the difference in cost between the Brand-Name Drug dispensed and its generic equivalent. The Copayment for the Brand-Name Drug will not apply. The Member?s payment will apply to the Out-of-Pocket Amount. For 2-tier plans, the plan participant must pay the generic drug coinsurance, plus the difference in cost between the brand-name drug dispensed and its generic equivalent. |
YES | $80.00 Copay after deductible |
$80.00 Copay after deductible |
Nutritional Counseling
Covered under Dietician visits. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Limitations, including dollar limits, may apply. Subject to Dental deductible, if applicable. Limitations may apply. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $40.00 |
60.00% Coinsurance after deductible |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Outpatient Rehabilitation Services
Exclusions: Other exclusions include but not limited to: Visual therapy lifestyle/habit changing clinics and/or programs; recreational therapy; primarily to enhance athletic abilities; and/or inpatient pain rehabilitation and inpatient pain control programs Rehabilitative Benefits are available for services provided on an Outpatient basis when the services are rendered by a licensed Provider. |
YES | $40.00 |
60.00% Coinsurance after deductible |
Outpatient Surgery Physician/Surgical Services
Exclusions: Exclusions include but not limited to: a. rhinoplasty; b. blepharoplasty services identified by CPT codes 15820, 15821, 15822, 15823; brow ptosis identified by CPT code 67900; or any revised or equivalent codes; c. gynecomastia; d. breast enlargement or reduction, except for breast reconstructive services as specifically provided in this Benefit Plan; e. implantation, removal and/or re-implantation of breast implants and services, illnesses, conditions, complications and/or treatment in relation to or as a result of breast implants; f. implantation, removal and/or re-implantation of penile prosthesis and services, illnesses, conditions, complications and/or treatment in relation to or as a result of penile prosthesis; g. diastasis recti; h. biofeedback; i. treatment related to erectile or sexual dysfunctions, low sexual desire disorder or other sexual inadequacies. j. Surgical and medical treatment for snoring in the absence of obstructive sleep apnea, including laser assisted uvulopalatoplasty (LAUP). k. Reversal of a voluntary sterilization procedure. Surgical services examples include but not limited to: 1. The Allowable Charge for Inpatient and Outpatient Surgery includes all pre-operative and postoperative medical visits. 2. Multiple Surgical Procedures - When Medically Necessary multiple procedures (concurrent, successive, or other multiple surgical procedures) are performed at the same surgical setting 3. Assistant Surgeon 4. General anesthesia services are covered when requested by the operating Physician and performed by a certified registered nurse anesthetist (CRNA) or Physician, other than the operating Physician or the assistant surgeon, for covered surgical services. Outpatient Medical and Surgical Services include: 1. Home, office, and other Outpatient visits for examination, diagnosis, and treatment of an illness or injury. Benefits for Outpatient medical services do not include separate payments for routine pre-operative and post-operative medical visits for Surgery or Pregnancy Care. 2. Services of an Ambulatory Surgical Center 3. Consultation (as defined in this Benefit Plan) |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Preferred Brand Drugs
Exclusions: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions. Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. Note that for 3-tier and 4-tier plans, when a Brand-Name Drug is dispensed and a generic equivalent exists, Members must pay theTier 1 Drug Copayment amount, plus the difference in cost between the Brand-Name Drug dispensed and its generic equivalent. The Copayment for the Brand-Name Drug will not apply. The Member?s payment will apply to the Out-of-Pocket Amount. For 2-tier plans, the plan participant must pay the generic drug coinsurance, plus the difference in cost between the brand-name drug dispensed and its generic equivalent. |
YES | $40.00 |
$40.00 |
Prenatal and Postnatal Care
|
YES | $80.00 |
60.00% Coinsurance after deductible |
Prescription Drugs Other
Some drugs covered under medical benefit. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Preventive Care/Screening/Immunization
Exclusions: Any services not included in the following Non-Grandfathered Preventive Care Services Brochure link is excluded: https://www.bcbsla.com/preventive Use the following Non-Grandfathered Preventive Care Services Brochure link for a complete list ? limitation and ages may vary: https://www.bcbsla.com/preventive Listed below is a sample of the Preventative/Screening/Immunization Benefits. Please refer to the member contract for more comprehensive list. EXAMINATIONS AND TESTING: Routine Wellness Physical Examination?Certain routine wellness diagnostic tests ordered by Your Physician are covered. Well Baby Care; Prostate Cancer Screening; Colorectal Cancer Screening; IMMUNIZATION: All state mandated immunizations including the complete basic immunization series as defined by the state health officer and required for school entry for children up to age six (6) SCREENING AND COUNSELING: Abdominal Aortic Aneurysm Screening; Alcohol Misuse Screening and Counseling; Blood Pressure Screening; Cholesterol Screening; Depression Screening; Type 2 Diabetes Screening; Diet Counseling; HIV Screening; Obesity Screening and Counseling; Sexually Transmitted Infection Counseling; Tobacco Use Screening; Syphilis Screening; COVERED SERVICES FOR WOMEN: Counseling for - BRCA genetic testing and breast cancer chemoprevention; Routine Gynecologist / Obstetrician Visits; Mammography Examination; Osteoporosis Screening; Routine Pap Smear; Screening ?Chlamydia Infection and Gonorrhea; COVERED SERVICES FOR PREGNANT WOMEN: Anemia Screening; Bacteriuria Screening; Breast Feeding Intervention; Folic Acid Supplements; Hepatitis B Screening; Rh Incompatibility Screening; COVERED SERVICES FOR CHILDREN: Alcohol and Drug Use Assessments; Autism Screening; Behavioral Assessments; Cervical Dysplasia Screening; Congenital Hypothyroidism Screening; Developmental Screening; Dyslipidemia Screening |
YES | 0.00% |
60.00% Coinsurance after deductible |
Primary Care Visit to Treat an Injury or Illness
The Physician Office Copayment may be reduced or waived when services are rendered by a Provider participating in the Quality Blue Program (QB). QB Providers include family practitioners, general practitioners, pediatricians, internists, geriatricians, nurse practitioners, and physician assistants, but more Providers may contract to participate in the Quality Blue program. The Physician Office Copayment may also be reduced or waived when services are rendered by a Provider participating in the Affinity Health Group. |
YES | $40.00 |
60.00% Coinsurance after deductible |
Private-Duty Nursing
Inpatient Private Duty Nursing Services are not covered. Plan limits coverage for Outpatient Private Duty Nursing Services to three hundred (300) hours per Benefit Period. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Prosthetic Devices
Benefits will be available for the purchase of Prosthetic Appliances and Devices and Prosthetic Services of the limbs that we Authorize. Repair or replacement of the Prosthetic Appliance or Device is covered only within a reasonable time period from the date of purchase subject to the expected lifetime of the appliance. We will determine this time period. Prosthetic Appliances and Devices of the limb must be prescribed by a licensed Physician and provided by a facility accredited by the American Board for Certification in Orthotics Prosthetics and Pedorthics (ABC) or by the Board for Orthotist/Prosthetist Certification (BOC). |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Radiation
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Reconstructive Surgery
1. Under the Women?s Health and Cancer Rights Act, a Member who is receiving Benefits in connection with a mastectomy and elects breast reconstruction will also receive Benefits for the following Covered Services: a. All stages of reconstruction of the breast on which a partial or full unilateral mastectomy has been performed or reconstruction of both breasts if a bilateral mastectomy has been performed; b. Surgery and reconstruction of the other breast to produce a symmetrical appearance, including but not limited to liposuction performed for transfer to a reconstructed breast or to repair a donor site deformity, tattooing the areola of the breast, surgical adjustments of the non-mastectomized breast, unforeseen medical Complications which may require additional reconstruction in the future; c. prostheses; and d. treatment of physical Complications of all stages of the mastectomy, including lymphedemas. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Care Benefits will be available for Services provided on a Inpatient or Outpatient basis, including services for Occupational Therapy, Physical Therapy, Speech/Language Pathology Therapy, and/or Chiropractic Services. |
YES | $40.00 |
60.00% Coinsurance after deductible |
Rehabilitative Speech Therapy
Rehabilitative Care Benefits will be available for Services provided on a Inpatient or Outpatient basis, including services for Occupational Therapy, Physical Therapy, Speech/Language Pathology Therapy, and/or Chiropractic Services. |
YES | $40.00 |
60.00% Coinsurance after deductible |
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
Benefits are excluded for palliative or cosmetic care or treatment of the foot; supportive devices of the foot; and treatment of flat feet, except for Medically Necessary Surgery. Benefits are excluded for routine foot care, except as specifically provided. |
NO | ||
Skilled Nursing Facility
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Specialist Visit
If you have a copayment plan, the Specialist copayment may be reduced or waived when services are rendered by an Affinity Health Group Provider. |
YES | $80.00 |
60.00% Coinsurance after deductible |
Specialty Drugs
Exclusions: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions. Specialty drugs are distributed throughout all tiers including 2-tier, 3-tier, and 4-tier plans and the member is responsible to pay the applicable deductible/copay/coinsurance for that tier. Retail day supply limits (typically 30-day supply) apply. In addition, quantity per dispensing (QPD) limits/allowances are placed on certain specialty medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. |
YES | $125.00 Copay after deductible |
$125.00 Copay after deductible |
Substance Abuse Disorder Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Substance Abuse Disorder Outpatient Services
Office visits are covered same as primary care physician benefit. Covered Services will be only those, which are for treatment for abuse of alcohol, drugs or other chemicals, and the resultant physiological and/or psychological dependency, which develops with continued use. |
YES | $40.00 |
60.00% Coinsurance after deductible |
Transplant
Exclusions: Exclusions are but not limited to: any costs of donating an organ or tissue for transplant when a Member is a donor; the transplant of any non-human organ or tissue; or bone marrow transplants and stem cell rescue (autologous and allogeneic) are not covered, except as provided in this Benefit Plan. If any organ, tissue or bone marrow is sold rather than donated to a Member, the purchase price of such organ, tissue or bone marrow is not covered. Benefit available in network only. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
NO | ||
Urgent Care Centers or Facilities
|
YES | $60.00 |
60.00% Coinsurance after deductible |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | No Charge |
60.00% Coinsurance after deductible |
X-rays and Diagnostic Imaging
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.7001190078415149 |
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 Silver Off Exchange Plan |
Dental Only Plan | No |
Design Type | Design 2 |
Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
EHB Percent of Total Premium | 1.0 |
First Tier Utilization | 100% |
Formulary ID | LAF019 |
Formulary URL | URL |
HIOS Product ID | 19636LA024 |
Import Date | 2024-09-11 01:01:35 |
Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
Inpatient Copayment Maximum Days | 0 |
HSA Eligible | No |
New/Existing Plan | New |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
Issuer ID | 19636 |
Issuer Marketplace Marketing Name | HMO Louisiana |
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 | Yes |
Network ID | LAN006 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Emergency and non-emergency coverage subject to Blue Card Worldwide rules. |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Coverage available for covered benefits |
Plan Brochure | URL |
Plan Effective Date | 2025-01-01 |
Plan Expiration Date | 2025-12-31 |
Plan ID (Standard Component ID with Variant) | 19636LA0240024-00 |
Plan Marketing Name | Blue Connect Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan (L) |
Plan Type | POS |
Plan Variant Marketing Name | Blue Connect Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan (L) |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $820 |
SBC Scenario, Having a Baby, Copayment | $90 |
SBC Scenario, Having a Baby, Deductible | $5,000 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $1,500 |
SBC Scenario, Having Diabetes, Deductible | $140 |
SBC Scenario, Having Diabetes, Limit | $60 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $290 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,050 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | LAS008 |
Source Name | HIOS |
Plan ID | 19636LA0240024 |
State Code | LA |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $64000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $32000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $32,000 |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $40000 per group |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $20000 per person |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $20,000 |
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 | $10000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,000 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $30000 per group |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $15000 per person |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | $15,000 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $16000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,000 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $48000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $24000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $24,000 |
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, 10 Dec 2024 06:32 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