CareSource Ohio, Inc. health insurance plan with the Plan ID 77552OH0010208. The plan is called CareSource Marketplace Essential Silver.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.17% (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 5.83% 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 | 77552OH0010208 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Ohio | ||||||||||||||||||
Health Insurance Issuer | CareSource Ohio, Inc. | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 77552OH0010208-06 | ||||||||||||||||||
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 | Standard Off Exchange Plan - 77552OH0010208-00 Standard On Exchange Plan - 77552OH0010208-01 Open to Indians below 300% FPL - 77552OH0010208-02 Open to Indians above 300% FPL - 77552OH0010208-03 73% AV Silver Plan - 77552OH0010208-04 |
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Last Plan Update Date | Thu, 18 Aug 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
Coverage for nontherapeutic abortion is prohibited for Qualified Health Plans per Ohio Revised Code ? 3901.87. |
NO | ||
Accidental Dental
Limit: 3000.0 Dollars per Episode |
YES | 0.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
See plan documents for details on benefit limits |
YES | 25.00% Coinsurance after deductible |
100.00% |
Chemotherapy
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
Limit: 12.0 Visit(s) per Year Benefit limit applies for Osteopathic/Chiropractic Manipulation Therapy. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year See plan documents for details on benefit limits |
YES | $0.00 |
100.00% |
Diabetes Education
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Dialysis
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
Covered services include durable medical equipment, medical devices and supplies, prosthetics and appliances, including cochlear implants and eyeglasses/contact lenses (for cataract surgery or injury), and medical/surgical supplies and equipment that serve only a medical purpose for the management of disease. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period; (as required by the Women?s Health and Cancer Rights Act); Left Ventricular Artificial Devices (LVAD) covered only as bridge to heart transplant. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
Emergency room copay or coinsurance is waived if you are admitted to the hospital directly from the Emergency Department. |
YES | 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
Ambulance transports must be made to the closest local facility that can provide you with covered services appropriate for your medical condition. |
YES | 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year Limited to one pair of glasses or a 12-month supply of contact lenses per benefit year. |
YES | $0.00, 0.00% |
100.00% |
Gender Affirming Care
Surgery determined to be Medically Necessary is Covered |
YES | 0.00% Coinsurance after deductible |
100.00% |
Generic Drugs
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Habilitation Services
Limits may apply to some services; includes benefits for health care services and devices that help a person keep, learn or improve skills and functioning for daily living. Includes Physical, Occupational and Speech Therapy limited to 20 visits each. Autism Spectrum Disorder Services for children (0 - 21) includes: (1) Out-Patient Physical Rehabilitation Services including (a) Speech and Language therapy and/or Occupational therapy, 20 visits per year of each service; and (b) Adaptive Behavior Treatment, which include but are not limited to Applied Behavioral Analysis and (2) Mental/Behavioral Health Outpatient Services to provide consultation, assessment, development and oversight of treatment plans. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Hearing Aids
|
NO | ||
Home Health Care Services
Limit: 100.0 Visit(s) per Year When therapy services are provided in the home (including physical, speech, and occupational therapy) as part of home health care services, they are not subject to separate visit limits for therapy services. The 100 visit/year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting. A visit equals at least 4 hours. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Hospice Services
To be eligible for Hospice benefits, the patient must have a life expectancy of six months or less, as confirmed by the attending Physician. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
Exclusions: The diagnosis and treatment of underlying medical causes of infertility are generally covered, however infertility treatments, such as artificial insemination/invitro fertilization, are not covered |
YES | 0.00% Coinsurance after deductible |
100.00% |
Infusion Therapy
Home IV therapy includes but is not limited to: injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include |
YES | 0.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient medical care visits limited to one visit per day by any one physician. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
See plan documents for details on benefit limits |
YES | 45.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Inpatient Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
$0 for first three visits then No Charge after deductible |
YES | 0.00% Coinsurance after deductible |
100.00% |
Non-Preferred Brand Drugs
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Nutritional Counseling
Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services (includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors). |
YES | 0.00% Coinsurance after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Limited to Medically Necessary Orthodontia. See plan documents for details on benefit limits. |
YES | 55.00% Coinsurance after deductible |
100.00% |
Other Practitioner Office Visit (Nurse, Physician Assistant)
$0 for first three visits then No Charge after deductible when categorized as a PCP |
YES | 0.00% Coinsurance after deductible |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
See exclusions that are detailed in plan document; benefits for facility charges for Outpatient Services are payable for the removal of teeth or for other dental processes only if the patient?s medical condition or the dental procedure requires a Hospital setting to ensure the safety of the patient |
YES | 0.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Therapy Services rendered in the home as part of Home Care Services will be subject to the Home Care Services visit limits; outpatient rehabilitation services visit limits will not apply. If different types of Therapy Services are performed during one Physician Home Visit, Office Service, or Outpatient Service, then each different type of Therapy Service performed will be considered a separate Therapy Visit. Each Therapy Visit will count against the applicable maximum visits per Benefit Period listed below: Physical, Occupational and Speech Therapy limited to 20 visits each. Cardiac Rehabilitation limited to 36 visits. Pulmonary Rehabilitation limited to 20 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply. Benefit also includes Physical Medicine and Rehabilitation Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Prenatal and Postnatal Care
Includes post-delivery follow-up care performed, by a physician or nurse, within 72 hours of discharge, through home health care visits or, at patient?s discretion, in a medical setting. This coverage includes, but is not limited to parent education; assistance and training in breast or bottle feeding; and routine maternal or neonatal tests and screening (including collection of sample for hereditary and metabolic newborn screening). |
YES | 0.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
Services with an 'A' or 'B' rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration including: women?s contraceptives, sterilization procedures, and counseling; breastfeeding support, supplies, and counseling (benefits for breast pumps are limited to one pump per benefit period); and gestational diabetes screening; routine screening mammograms; routine cytologic screening; child health supervision services from birth to age 9. |
YES | 0.00% |
100.00% |
Primary Care Visit to Treat an Injury or Illness
$0 for first three visits then No Charge after deductible |
YES | 0.00% Coinsurance after deductible |
100.00% |
Private-Duty Nursing
Limit: 100.0 Visit(s) per Year Private Duty Nursing Services are Covered Services only when provided through the Home Care Services benefit; A visit equals 8 hours. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Prosthetic Devices
Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that 1) Replace all or part of a missing body part and its adjoining tissues; or 2) Replace all or part of the function of a permanently useless or malfunctioning body part. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Quantitative limit units apply, see Summary of Benefits and Coverage. $0 for first three visits then No Charge after deductible |
YES | 0.00% Coinsurance after deductible |
100.00% |
Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year |
YES | 0.00% Coinsurance after deductible |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | $0.00, 0.00% |
100.00% |
Routine Foot Care
|
NO | ||
Skilled Nursing Facility
Limit: 90.0 Days per Year Benefits include Items and services provided as an inpatient in a skilled nursing bed of skilled nursing facility or hospital, including room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Specialty Drugs
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
$0 for first three visits then No Charge after deductible |
YES | 0.00% Coinsurance after deductible |
100.00% |
Transplant
Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined). Transplant benefits apply to any medically necessary human organ and stem cell/bone marrow transplants (except cornea and kidney transplants) and transfusions including necessary acquisition procedures, harvest and storage, necessary preparatory myeloablative therapy, and initial evaluation/testing to determine eligibility as a transplant candidate. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
X-rays and Diagnostic Imaging
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.941680745 |
Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
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 | 94% AV Level Silver Plan |
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 |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 100% |
Formulary ID | OHF006 |
Formulary URL | URL |
HIOS Product ID | 77552OH001 |
Import Date | 8/18/2022 20:01 |
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 | Yes |
Is a Referral Required for Specialist? | No |
Issuer ID | 77552 |
Issuer Marketplace Marketing Name | CareSource |
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 | OHN001 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Emergency Services Only |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Emergency Services Only |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 77552OH0010208-06 |
Plan Marketing Name | CareSource Marketplace Essential Silver |
Plan Type | HMO |
Plan Variant Marketing Name | CareSource Marketplace Essential Silver 3 |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $600 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $0 |
SBC Scenario, Having Diabetes, Deductible | $600 |
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 | $600 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | OHS001 |
Source Name | SERFF |
Plan ID | 77552OH0010208 |
State Code | OH |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $1200 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $600 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $600 |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $1200 per group |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $600 per person |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $600 |
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 | $1200 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $600 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $600 |
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 | $1200 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $600 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $600 |
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 | 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, 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