CareSource Marketplace Gold Dental, Vision, & Fitness - 50328WV0020022 Health Insurance Plan
CareSource West Virginia Co. health insurance plan with the Plan ID 50328WV0020022. The plan is called CareSource Marketplace Gold Dental, Vision, & Fitness.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.02% (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 21.98% 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 | 50328WV0020022 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | West Virginia | ||||||||||||||||||
| Health Insurance Issuer | CareSource West Virginia Co. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 50328WV0020022-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| 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 - 50328WV0020022-00 Standard On Exchange Plan - 50328WV0020022-01 |
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| Last Plan Update Date | Tue, 15 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Benefits of CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, 50328WV0020022-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Surgery determined to be Medically Necessary is covered. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits. |
YES | 15.00% |
100.00% |
| Basic Dental Care - Child
See plan documents for details on benefit limits. |
YES | 15.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Benefit Period |
YES | $60.00 |
100.00% |
| Chronic Pain Treatment
Limit: 20.0 Visit(s) per Episode Physical Therapy, Occupational Therapy, Osteopathic Manipulation, a Chronic Pain Management Program, and Chiropractic Services limited to 20 combined visits per event. Separate limits from Rehabilitative and Habilitative services. |
YES | $30.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Diabetes Education
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 25.00% 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 | 25.00% Coinsurance after deductible |
25.00% 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 | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Limited to one pair of glasses or contact lenses per benefit year. |
YES | No Charge |
100.00% |
| Gender Affirming Care
Surgery determined to be Medically Necessary is Covered |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
|
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Physical Therapy & Occupational Therapy limited to 30 visits each per benefit period.? Autism Spectrum Disorder Services with limits combined with Habilitative Services. |
YES | $30.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period The following are Covered Services when you are Homebound and receive them from a Hospital or a Home Health Care Agency: Intermittent Skilled Care rendered by a registered or licensed practical nurse or nurse-midwife; Physical therapy, occupational therapy or speech therapy; Medical and surgical supplies; Prescription Drugs; Oxygen and its administration; Medical social Services; Home health aide visits when you are also receiving Skilled Care or Therapy Services; Laboratory tests; Home infusion therapy.<br> |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Must have a terminal illness with life expectancy of 6 months or less. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
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 | 25.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits. |
YES | 40.00% |
100.00% |
| Major Dental Care - Child
See plan documents for details on benefit limits. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
Your Prescription Drug benefits may include a Formulary ... which is a list of Brand Name Prescription Drugs that are preferred by your Plan. We may remind your Physician or Professional Other Provider when a Formulary medication is available for a medication that is not on your Formulary. This may result in a change in your Prescription. However, your Physician or Professional Other Provider will always make the final decision on your medication.<br> |
YES | $60.00 |
100.00% |
| Nutritional Counseling
Diet education covered in the context of diabetes self-management education. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Limited to Medically Necessary Orthodontia. See plan documents for details on benefit limits. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period Physical Therapy, Occupational Therapy, and Pulmonary Rehabilitation limited to 30 visits each per benefit period.? Cardiac Rehabilitation limited to 36 visits per benefit period. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $60.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
| Private-Duty Nursing
Limit: 35.0 Visit(s) per Benefit Period A visit equals 8 hours or less. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
(a) only those that restore a body function or which were caused by disease, trauma, birth defects, growth defects, prior therapeutic processes; or (b) reconstructive Surgery following Covered Services for a mastectomy, including reconstruction of the other breast for the purpose of restoring symmetry; or (c) reconstructive or cosmetic Surgery necessary as a result of an act of family violence.<br> |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period 30 visit each for Occupational and Physical Therapies. |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
|
YES | $30.00 |
100.00% |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year $1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits. |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
|
YES | $50.00 |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
|
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
100.00% |
| Transplant
Quantitative limit units apply, see Summary of Benefits and Coverage. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $45.00 |
$45.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan Variant 50328WV0020022-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7801851164396751 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| 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 | 0.9894332360296141 |
| First Tier Utilization | 100% |
| Formulary ID | WVF002 |
| Formulary URL | URL |
| HIOS Product ID | 50328WV002 |
| Import Date | 2023-08-15 20:02:25 |
| 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 | 50328 |
| Issuer Marketplace Marketing Name | CareSource |
| Market Coverage | Individual |
| 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 | WVN001 |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 50328WV0020022-00 |
| Plan Marketing Name | CareSource Marketplace Gold Dental, Vision, & Fitness |
| Plan Type | HMO |
| Plan Variant Marketing Name | CareSource Marketplace Gold Dental, Vision, & Fitness |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,100 |
| SBC Scenario, Having a Baby, Copayment | $70 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $600 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $1,500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WVS001 |
| Source Name | SERFF |
| Plan ID | 50328WV0020022 |
| State Code | WV |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $8,700 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| 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 | $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 | 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 |
Copay & Coinsurance of CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, 50328WV0020022
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about CareSource Marketplace Gold Dental, Vision, & Fitness, 50328WV0020022 Health Insurance Plan, 50328WV0020022
-
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, 50328WV0020022 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (50328WV0020022) Health Insurance Plan, Variant (50328WV0020022-00) offer Disease Management Programs?
Does (50328WV0020022) Health Insurance Plan, Variant (50328WV0020022-00) have Out Of Country Coverage?
Does (50328WV0020022) Health Insurance Plan, Variant (50328WV0020022-00) have Out of Service Area Coverage?
Does (50328WV0020022) Health Insurance Plan, Variant (50328WV0020022-00) offer Disease Management Programs?
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, Variant (50328WV0020022-00) offer Disease Management Programs for Asthma?
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, Variant (50328WV0020022-00) offer Disease Management Programs for Heart disease?
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, Variant (50328WV0020022-00) offer Disease Management Programs for Depression?
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, Variant (50328WV0020022-00) offer Disease Management Programs for Diabetes?
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, Variant (50328WV0020022-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, Variant (50328WV0020022-00) offer Disease Management Programs for Low back pain?
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, Variant (50328WV0020022-00) offer Disease Management Programs for Pregnancy?
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