CareSource Marketplace Low Premium Silver - 54192IN0010011 Health Insurance Plan

CareSource Indiana, Inc. health insurance plan with the Plan ID 54192IN0010011. The plan is called CareSource Marketplace Low Premium Silver.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.05% (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 12.95% 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 54192IN0010011
Health Insurance Plan Year 2023
State Indiana
Health Insurance Issuer CareSource Indiana, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Last Plan Update Date Fri, 18 Nov 2022 00:00 GMT
Last Import Date Fri, 01 Dec 2023 08:11 GMT
Health Insurance Plan Variant 54192IN0010011-05
 
Available Variants of the Health Plan

Standard Off Exchange Plan - 54192IN0010011-00

Standard On Exchange Plan - 54192IN0010011-01

Open to Indians below 300% FPL - 54192IN0010011-02

Open to Indians above 300% FPL - 54192IN0010011-03

73% AV Silver Plan - 54192IN0010011-04

87% AV Silver Plan - 54192IN0010011-05

94% AV Silver Plan - 54192IN0010011-06

Benefits of CareSource Marketplace Low Premium Silver Health Insurance Plan, 54192IN0010011-05

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental

Limit: 3000.0 Dollars per Episode

Injury as a result of chewing or biting is not considered an accidental injury.

YES

20.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

20.00% 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

20.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 12.0 Visit(s) per Year

YES

20.00% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

$350.00 Copay after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Exam(s) per Year

YES

$0.00

100.00%
Diabetes Education
YES

20.00% Coinsurance after deductible

100.00%
Dialysis
YES

20.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

20.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

$350.00 Copay after deductible

$350.00 Copay 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

20.00% Coinsurance after deductible

20.00% 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

$0.00, 0.00%

100.00%
Gender Affirming Care
YES

20.00% Coinsurance after deductible

100.00%
Generic Drugs
YES

$10.00

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Year

Physical Therapy, Occupational Therapy, and Speech Therapy limited to 20 visits each per benefit period.

YES

$5.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 100.0 Visit(s) per Benefit Period

A visit equals at least 4 hours. Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home.

YES

20.00% Coinsurance after deductible

100.00%
Hospice Services
YES

20.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$200.00 Copay after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

20.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis).

YES

$350.00 Copay per Stay after deductible

100.00%
Inpatient Physician and Surgical Services
YES

0.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

$15.00

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

$350.00 Copay per Stay after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$5.00

100.00%
Non-Preferred Brand Drugs
YES

40.00% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

20.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Limited to Medically Necessary Orthodontia. See plan documents for details on benefit limits.

YES

50.00% Coinsurance after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$5.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

20.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Year

Physical Therapy, Occupational Therapy, and Speech Therapy limited to 20 visits each per benefit period.? Cardiac Rehabilitation limited to 36 visits.

YES

20.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$40.00

100.00%
Prenatal and Postnatal Care
YES

$40.00

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$5.00

100.00%
Private-Duty Nursing

Limit: 100.0 Visit(s) per Year

A visit equals 8 hours.

YES

20.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

20.00% Coinsurance after deductible

100.00%
Radiation
YES

20.00% 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

20.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Year

Physical Therapy and Occupational Therapy limited to 20 visits each per benefit period.

YES

$5.00

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

YES

20.00% 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

YES

$300.00 Copay per Stay after deductible

100.00%
Specialist Visit
YES

$40.00

100.00%
Specialty Drugs
YES

45.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

$350.00 Copay per Stay after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$5.00

100.00%
Transplant

Quantitative limit units apply, see Summary of Benefits and Coverage.

YES

20.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

20.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$25.00

$25.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

0.00%

100.00%
X-rays and Diagnostic Imaging
YES

$150.00 Copay after deductible

100.00%

CareSource Marketplace Low Premium Silver 2 Health Insurance Plan Variant 54192IN0010011-05 Attributes

Plan Attribute Value
AV Calculator Output Number 0.870484335
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 87% 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 INF004
Formulary URL URL
HIOS Product ID 54192IN001
Import Date 11/18/2022 1:01
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 54192
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 INN001
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) 54192IN0010011-05
Plan Marketing Name CareSource Marketplace Low Premium Silver
Plan Type HMO
Plan Variant Marketing Name CareSource Marketplace Low Premium Silver 2
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $700
SBC Scenario, Having a Baby, Deductible $1,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $600
SBC Scenario, Having Diabetes, Copayment $300
SBC Scenario, Having Diabetes, Deductible $1,000
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $100
SBC Scenario, Treatment of a Simple Fracture, Copayment $600
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,000
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID INS001
Source Name HIOS
Plan ID 54192IN0010011
State Code IN
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $5600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $2800 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $2,800
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $2000 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $1000 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $1,000
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $2000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,000
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 $5600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $2800 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $2,800
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 Low Premium Silver Health Insurance Plan, 54192IN0010011

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about CareSource Marketplace Low Premium Silver, 54192IN0010011 Health Insurance Plan, 54192IN0010011

  • Does CareSource Marketplace Low Premium Silver Health Insurance Plan, 54192IN0010011 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (54192IN0010011) Health Insurance Plan, Variant (54192IN0010011-05) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does (54192IN0010011) Health Insurance Plan, Variant (54192IN0010011-05) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (54192IN0010011) Health Insurance Plan, Variant (54192IN0010011-05) have Out of Service Area Coverage?

    Yes. Details: Emergency Services Only

    Does (54192IN0010011) Health Insurance Plan, Variant (54192IN0010011-05) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does CareSource Marketplace Low Premium Silver 2 Health Insurance Plan, Variant (54192IN0010011-05) offer Disease Management Programs for Asthma?

    Yes, the CareSource Marketplace Low Premium Silver 2 Health Insurance Plan Variant 54192IN0010011-05 offers Disease Management Program for Asthma.

    Does CareSource Marketplace Low Premium Silver 2 Health Insurance Plan, Variant (54192IN0010011-05) offer Disease Management Programs for Heart disease?

    Yes, the CareSource Marketplace Low Premium Silver 2 Health Insurance Plan Variant 54192IN0010011-05 offers Disease Management Program for Heart disease.

    Does CareSource Marketplace Low Premium Silver 2 Health Insurance Plan, Variant (54192IN0010011-05) offer Disease Management Programs for Depression?

    Yes, the CareSource Marketplace Low Premium Silver 2 Health Insurance Plan Variant 54192IN0010011-05 offers Disease Management Program for Depression.

    Does CareSource Marketplace Low Premium Silver 2 Health Insurance Plan, Variant (54192IN0010011-05) offer Disease Management Programs for Diabetes?

    Yes, the CareSource Marketplace Low Premium Silver 2 Health Insurance Plan Variant 54192IN0010011-05 offers Disease Management Program for Diabetes.

    Does CareSource Marketplace Low Premium Silver 2 Health Insurance Plan, Variant (54192IN0010011-05) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the CareSource Marketplace Low Premium Silver 2 Health Insurance Plan Variant 54192IN0010011-05 offers Disease Management Program for High blood pressure & high cholesterol.

    Does CareSource Marketplace Low Premium Silver 2 Health Insurance Plan, Variant (54192IN0010011-05) offer Disease Management Programs for Low back pain?

    Yes, the CareSource Marketplace Low Premium Silver 2 Health Insurance Plan Variant 54192IN0010011-05 offers Disease Management Program for Low back pain.

    Does CareSource Marketplace Low Premium Silver 2 Health Insurance Plan, Variant (54192IN0010011-05) offer Disease Management Programs for Pregnancy?

    Yes, the CareSource Marketplace Low Premium Silver 2 Health Insurance Plan Variant 54192IN0010011-05 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Fri, 01 Dec 2023 08:11 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