Clear Silver + Vision + Adult Dental - 61604LA0020015 Health Insurance Plan

Louisiana Healthcare Connections Inc. health insurance plan with the Plan ID 61604LA0020015. The plan is called Clear Silver + Vision + Adult Dental.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.12% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.88% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 61604LA0020015
Health Insurance Plan Year 2023
State Louisiana
Health Insurance Issuer Louisiana Healthcare Connections Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 61604LA0020015-00
Provider Network(s) ['LAN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT).

Providers Louisiana All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 61604LA0020015-00

Standard On Exchange Plan - 61604LA0020015-01

Open to Indians below 300% FPL - 61604LA0020015-02

Open to Indians above 300% FPL - 61604LA0020015-03

73% AV Silver Plan - 61604LA0020015-04

87% AV Silver Plan - 61604LA0020015-05

94% AV Silver Plan - 61604LA0020015-06

Last Plan Update Date Fri, 24 Feb 2023 00:00 GMT
Last Import Date Tue, 22 Oct 2024 06:47 GMT

Benefits of Clear Silver + Vision + Adult Dental Health Insurance Plan, 61604LA0020015-00

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

No Charge after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

No Charge after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

YES

50.00%

100.00%
Basic Dental Care - Child
NO
Chemotherapy

High-dose chemotherapy to support transplant procedures.

YES

No Charge after deductible

100.00%
Chiropractic Care
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Diabetic Self-Management/Diabetic Education is subject to applicable deductible, coinsurance & copayment amounts; member's cost share shall not exceed more than $500 dollars for a one time evaluation and training program. Additional Diabetes Self-Management/Diabetic Education, if medically necessary because of a significant change in a member's symptoms or conditions, is also covered; member's cost share shall not exceed more than $100 dollars per year.

YES

No Charge after deductible

100.00%
Dialysis
YES

No Charge after deductible

100.00%
Durable Medical Equipment

Medical Foods/Low protein food products for the treatment of inherited metabolic diseases are subject to applicable deductible, coinsurance & copayment amounts; member's cost share shall not exceed more than $200 dollars per month.

YES

No Charge after deductible

100.00%
Emergency Room Services
YES

No Charge after deductible

No Charge after deductible
Emergency Transportation/Ambulance

Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.

YES

No Charge after deductible

No Charge after deductible
Eyeglasses for Adults

Limit: 1.0 Item(s) per Year

Need to have allowance of $130 Dollars

YES

No Charge

100.00%
Eye Glasses for Children
YES

No Charge

100.00%
Gender Affirming Care
YES

No Charge after deductible

100.00%
Generic Drugs

Most Ambetter Plans offer Preferred Generic Drugs at $5 or less. Please see plan's Summary of Benefits and Coverage (SBC) or policy document for Preferred Generic and Generic prescription drug cost.

YES

No Charge after deductible

100.00%
Habilitation Services

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

No Charge after deductible

100.00%
Hearing Aids

Limit: 2.0 Item(s) per 3 Years

YES

No Charge 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

No Charge after deductible

100.00%
Hospice Services
YES

No Charge after deductible

100.00%
Imaging (CT/PET Scans, MRIs)

Cost share is based on place of service.

YES

No Charge after deductible

100.00%
Infertility Treatment

Coverage is available for diagnosis and services required to correct underlying medical causes of infertility.

NO
Infusion Therapy
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Inpatient Physician and Surgical Services
YES

No Charge after deductible

100.00%
Laboratory Outpatient and Professional Services

Cost share is based on place of service.

YES

No Charge after deductible

100.00%
Long-Term/Custodial Nursing Home Care

Long Term Acute Care is a covered benefit. Long Term Nursing Care/ Custodial Care is not a covered benefit.

NO
Major Dental Care - Adult

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

YES

50.00%

100.00%
Major Dental Care - Child
NO
Mental/Behavioral Health Emergency Room
YES

No Charge after deductible

No Charge after deductible
Mental/Behavioral Health Emergency Transportation/Ambulance
YES

No Charge after deductible

No Charge after deductible
Mental/Behavioral Health ER Physician Fee
YES

No Charge after deductible

No Charge after deductible
Mental/Behavioral Health Inpatient Services

Inpatient treatment for mental/behavioral health disorders must be Authorized as provided in the Care Management Article of this Benefit Plan.

YES

No Charge after deductible

100.00%
Mental/Behavioral Health Outpatient Other Services
YES

No Charge after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

No Charge after deductible

100.00%
Mental/Behavioral Health Urgent Care
YES

No Charge after deductible

100.00%
Non-Preferred Brand Drugs
YES

No Charge after deductible

100.00%
Nutritional Counseling

Coverage only for diabetes education.

YES

No Charge after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Outpatient Rehabilitation Services
YES

No Charge after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge after deductible

100.00%
Preferred Brand Drugs
YES

No Charge after deductible

100.00%
Prenatal and Postnatal Care
YES

No Charge after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge

YES

No Charge after deductible

100.00%
Private-Duty Nursing
YES

No Charge after deductible

100.00%
Prosthetic Devices
YES

No Charge after deductible

100.00%
Radiation
YES

No Charge after deductible

100.00%
Reconstructive Surgery

Breast Reconstructive Surgery Services.

YES

No Charge after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

No Charge after deductible

100.00%
Rehabilitative Speech Therapy
YES

No Charge after deductible

100.00%
Routine Dental Services (Adult)

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

YES

No Charge

100.00%
Routine Eye Exam (Adult)

Limit: 1.0 Exam(s) per Year

YES

No Charge

100.00%
Routine Eye Exam for Children
YES

No Charge

100.00%
Routine Foot Care

Coverage is limited to diabetes care only.

NO
Skilled Nursing Facility
YES

No Charge after deductible

100.00%
Specialist Visit
YES

No Charge after deductible

100.00%
Specialty Drugs

Limited to copayment or coinsurance applicable to specialty tiered drug amount not to exceed one hundred and fifty dollars per month for each drug up to a thirty-day supply, after deductible is met).

YES

No Charge after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Inpatient treatment for substance abuse must be Authorized as provided in the Care Management Article of this Benefit Plan, when coverage for alcohol and/or drug abuse is provided.

YES

No Charge after deductible

100.00%
Substance Abuse Disorder Outpatient Services

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

No Charge after deductible

100.00%
Substance Use Disorder Emergency Room
YES

No Charge after deductible

No Charge after deductible
Substance Use Disorder Emergency Transportation/Ambulance
YES

No Charge after deductible

No Charge after deductible
Substance Use Disorder ER Physician Fee
YES

No Charge after deductible

No Charge after deductible
Substance Use Disorder Outpatient Other Services
YES

No Charge after deductible

100.00%
Substance Use Disorder Urgent Care
YES

No Charge after deductible

100.00%
Transplant

Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.

YES

No Charge after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

No Charge after deductible

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging

Cost share is based on place of service.

YES

No Charge after deductible

100.00%

Clear Silver + Vision + Adult Dental Health Insurance Plan Variant 61604LA0020015-00 Attributes

Plan Attribute Value
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 Standard Silver Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 0.964
First Tier Utilization 100%
Formulary ID LAF008
Formulary URL URL
HIOS Product ID 61604LA002
Import Date 2/24/2023 1:01
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 Actuarial Value 70.12%
Issuer ID 61604
Issuer Marketplace Marketing Name Ambetter from Louisiana Healthcare Connections
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 LAN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 61604LA0020015-00
Plan Marketing Name Clear Silver + Vision + Adult Dental
Plan Type HMO
Plan Variant Marketing Name Clear Silver + Vision + Adult Dental
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $5,400
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $5,400
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 $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID LAS001
Source Name HIOS
Plan ID 61604LA0020015
State Code LA
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
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 $10800 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5400 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,400
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 $10800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $5400 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $5,400
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 Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Clear Silver + Vision + Adult Dental Health Insurance Plan, 61604LA0020015

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

Frequently Asked Questions(FAQ) about Clear Silver + Vision + Adult Dental, 61604LA0020015 Health Insurance Plan, 61604LA0020015

  • Does Clear Silver + Vision + Adult Dental Health Insurance Plan, 61604LA0020015 support Mail Ordering?

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

  • Does (61604LA0020015) Health Insurance Plan, Variant (61604LA0020015-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does (61604LA0020015) Health Insurance Plan, Variant (61604LA0020015-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (61604LA0020015) Health Insurance Plan, Variant (61604LA0020015-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

    Does (61604LA0020015) Health Insurance Plan, Variant (61604LA0020015-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does Clear Silver + Vision + Adult Dental Health Insurance Plan, Variant (61604LA0020015-00) offer Disease Management Programs for Asthma?

    Yes, the Clear Silver + Vision + Adult Dental Health Insurance Plan Variant 61604LA0020015-00 offers Disease Management Program for Asthma.

    Does Clear Silver + Vision + Adult Dental Health Insurance Plan, Variant (61604LA0020015-00) offer Disease Management Programs for Heart disease?

    Yes, the Clear Silver + Vision + Adult Dental Health Insurance Plan Variant 61604LA0020015-00 offers Disease Management Program for Heart disease.

    Does Clear Silver + Vision + Adult Dental Health Insurance Plan, Variant (61604LA0020015-00) offer Disease Management Programs for Diabetes?

    Yes, the Clear Silver + Vision + Adult Dental Health Insurance Plan Variant 61604LA0020015-00 offers Disease Management Program for Diabetes.

    Does Clear Silver + Vision + Adult Dental Health Insurance Plan, Variant (61604LA0020015-00) offer Disease Management Programs for Pregnancy?

    Yes, the Clear Silver + Vision + Adult Dental Health Insurance Plan Variant 61604LA0020015-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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