USAble Mutual Insurance Company health insurance plan with the Plan ID 75293AR1200007. The plan is called Bronze Plan 1.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 75293AR1200007 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Arkansas | ||||||||||||||||||
Health Insurance Issuer | USAble Mutual Insurance Company | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 75293AR1200007-02 | ||||||||||||||||||
Provider Network(s) | ['ARN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 21 May 2024 06:25 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 75293AR1200007-00 Standard On Exchange Plan - 75293AR1200007-01 |
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Last Plan Update Date | Mon, 12 Sep 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 21 May 2024 06:25 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Acupuncture
|
NO | ||
Allergy Testing
SOB includes 'allergy services.' |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Applied Behavior Analysis Based Therapies
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Chemotherapy
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Chiropractic Care
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $0.00, 0.00% |
100.00% |
Cochlear Implants
Requires Prior Approval from the Company. One cochlear implant per ear per Covered Person per lifetime |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Cosmetic Surgery
|
NO | ||
Craniofacial Surgery
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services: 75293AR1200007-01-0% Coinsurance after deductible for in-network and out-of-network services; 75293AR1200007-02-No charge for in-network and out-of-network services; 75293AR1200007-03-0% Coinsurance after deductible for in-network and out-of-network services; Coverage for Out of Network newborn services is limited to $2000 per person for all services first 90 days after birth. Coverage requires Prior Notification to the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Dental Anesthesia
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Care Management
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Diabetes Education
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Dialysis
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Durable Medical Equipment
Requires Prior Approval from the Company for services $500 or more |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Emergency Room Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Emergency Transportation/Ambulance
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Gastric Electrical Stimulation
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Gender Affirming Care
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
100.00% |
Generic Drugs
|
YES | $0.00, 0.00% |
100.00% |
Habilitation Services
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro; Limited to a maximum of 180 units for developmental services visits per Covered Person per calendar year. |
YES | $0.00, 0.00% |
100.00% |
Hearing Aids
Coverage is limited to $1400/ear |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Home Health Care Services
Limit: 50.0 Visit(s) per Year Requires Prior Approval from the Company. Coverage is provided for Home Health Services when Coverage Policy supports the need for in-home service and such care is prescribed or ordered by a Physician. Covered Services must be provided through and billed by a licensed home health agency. Covered Services provided in the home include services of a Registered Professional Nurse (R.N.), a Licensed Practical Nurse (L.P.N.) or a Licensed Psychiatric Technical Nurse (L.P.T.N.). |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Hospice Services
Requires Prior Approval from the Company. If the Covered Person has been diagnosed and certified by the attending Physician as having a terminal illness with a life expectancy of six months or less, the Company will pay the Allowance or Allowable Charge for Hospice Care. The services must be rendered by an entity licensed by the Arkansas Department of Health or other appropriate state licensing agency and accepted by the Company as a Provider. This benefit is subject to the Deductible, Copayment and Coinsurance specified in the Schedule of Benefits. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Imaging (CT/PET Scans, MRIs)
Requires Prior Approval from the Company for high tech radiology services |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Infertility Treatment
Requires Prior Approval from the Company. 4 oocyte retrievals or 2 live births from separate pregnancies |
YES | $0.00, 0.00% |
100.00% |
Infusion Therapy
Home infusion therapy. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Inherited Metabolic Disorder - PKU
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Inpatient Physician and Surgical Services
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Laboratory Outpatient and Professional Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
NO | ||
Mental/Behavioral Health Inpatient Services
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Mental/Behavioral Health Outpatient Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Non-Preferred Brand Drugs
|
YES | $0.00, 0.00% |
100.00% |
Nutritional Counseling
Coverage is provided for dietary and nutritional counseling services when provided in conjunction with diabetic self-management training, for services needed by covered persons in connection with cleft palate management and for nutritional assessment programs provided in and by a hospital and approved by the company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Off Label Prescription Drugs
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $0.00, 0.00% |
100.00% |
Outpatient Surgery Physician/Surgical Services
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Preferred Brand Drugs
|
YES | $0.00, 0.00% |
100.00% |
Prenatal and Postnatal Care
Requires Prior Notification to the Company. Coverage for routine ultrasound is limited to 1. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Preventive Care/Screening/Immunization
Limit: 1.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
Preventive Drugs
|
YES | $0.00, 0.00% |
100.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
Requires Prior Approval from the Company for any device for which cost exceeds $5,000. Replaced no more frequently than once per 3-yr period except when necessary for growth or end of device's useful life. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Radiation
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Reconstructive Surgery
Requires Prior Approval from the Company. 1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Covered Person; 2. Surgery performed for the removal of a port-wine stain or hemangioma (only on the face) 3. Treatment provided for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria and is Prior Approved by the Company is covered. |
YES | $0.00, 0.00% |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $0.00, 0.00% |
100.00% |
Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $0.00, 0.00% |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per 2 Years |
YES | $0.00, 0.00% |
100.00% |
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | $0.00, 0.00% |
100.00% |
Routine Foot Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Skilled Nursing Facility
Limit: 60.0 Days per Year Requires Prior Approval from the Company. 1. The admission must be within seven days of release from an inpatient Hospital stay; 2. The Skilled Nursing Facility services are of a temporary nature and increase ability to function. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Specialist Visit
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Specialty Drugs
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
100.00% |
Specialty Drugs Tier 2
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
100.00% |
Substance Abuse Disorder Inpatient Services
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Substance Abuse Disorder Outpatient Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Transplant
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Treatment for Temporomandibular Joint Disorders
Requires Prior Approval from the Company. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Urgent Care Centers or Facilities
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | $0.00, 0.00% |
100.00% |
Well Child Care
|
YES | $0.00, 0.00% |
100.00% |
X-rays and Diagnostic Imaging
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 1 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Zero Cost Sharing Plan Variation |
Dental Only Plan | No |
Design Type | Not Applicable |
Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
EHB Percent of Total Premium | 0.9966 |
First Tier Utilization | 100% |
Formulary ID | ARF007 |
Formulary URL | URL |
HIOS Product ID | 75293AR120 |
Import Date | 9/12/2022 20:01 |
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 ID | 75293 |
Issuer Marketplace Marketing Name | Arkansas Blue Cross and Blue Shield |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Expanded Bronze |
Multiple In Network Tiers | No |
National Network | No |
Network ID | ARN001 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Emergency Care |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Benefit Reduction |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 75293AR1200007-02 |
Plan Level Exclusions | No |
Plan Marketing Name | Bronze Plan 1 |
Plan Type | PPO |
Plan Variant Marketing Name | Bronze Plan 1 |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $0 |
SBC Scenario, Having a Baby, Limit | $0 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $0 |
SBC Scenario, Having Diabetes, Deductible | $0 |
SBC Scenario, Having Diabetes, Limit | $60 |
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 | $0 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | ARS001 |
Source Name | SERFF |
Plan ID | 75293AR1200007 |
State Code | AR |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $0 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
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 | $0 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
Unique Plan Design | No |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | Yes |
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, 21 May 2024 06:25 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