Clear Silver + Vision + Adult Dental - 27833IL0150061 Health Insurance Plan

Celtic Insurance Company health insurance plan with the Plan ID 27833IL0150061. The plan is called Clear Silver + Vision + Adult Dental.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.04% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.96% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 27833IL0150061
Health Insurance Plan Year 2024
State Illinois
Health Insurance Issuer Celtic Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 27833IL0150061-03
Provider Network(s) PREFERRED
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 Illinois 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 - 27833IL0150061-00

Standard On Exchange Plan - 27833IL0150061-01

Open to Indians below 300% FPL - 27833IL0150061-02

Open to Indians above 300% FPL - 27833IL0150061-03

73% AV Silver Plan - 27833IL0150061-04

87% AV Silver Plan - 27833IL0150061-05

94% AV Silver Plan - 27833IL0150061-06

Last Plan Update Date Mon, 18 Dec 2023 00:00 GMT
Last Import Date Tue, 22 Oct 2024 06:47 GMT

Benefits of Clear Silver + Vision + Adult Dental Health Insurance Plan, 27833IL0150061-03

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

No Charge after deductible

100.00%
Accidental Dental
YES

No Charge after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

No Charge after deductible

100.00%
Autism Spectrum Disorders
YES

No Charge after deductible

100.00%
Bariatric Surgery
YES

No Charge after deductible

100.00%
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
Bones/Joints
YES

No Charge after deductible

100.00%
Breast Implant Removal
YES

No Charge after deductible

100.00%
Cardiac Rehabilitation
YES

No Charge after deductible

100.00%
Chemotherapy
YES

No Charge after deductible

100.00%
Chiropractic Care

Limit: 25.0 Visit(s) per Year

YES

No Charge after deductible

100.00%
Cosmetic Surgery

Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered.

YES

No Charge after deductible

100.00%
Delivery and All Inpatient Services for Maternity Care
YES

No Charge after deductible

100.00%
Dental Anesthesia
YES

No Charge after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

No Charge after deductible

100.00%
Dialysis
YES

No Charge after deductible

100.00%
Durable Medical Equipment
YES

No Charge after deductible

100.00%
Emergency Room Services
YES

No Charge after deductible

No Charge after deductible
Emergency Transportation/Ambulance

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
Eye Glasses for Adults
NO
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

No Charge

100.00%
Gender Affirming Care
YES

No Charge after deductible

100.00%
Generic Drugs

Cost sharing shown applies to Tier 2-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 3-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information.

YES

No Charge after deductible

100.00%
Habilitation Services
YES

No Charge after deductible

100.00%
Hearing Aids

Limit: 2.0 Item(s) per 2 Years

Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit.

YES

No Charge after deductible

100.00%
Home Health Care Services
YES

No Charge after deductible

100.00%
Hospice Services

Respite Care is covered as part of hospice services only.

YES

No Charge after deductible

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

No Charge after deductible

100.00%
Infertility Treatment
YES

No Charge after deductible

100.00%
Infusion Therapy
YES

No Charge after deductible

100.00%
Inherited Metabolic Disorder - PKU
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
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

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
Mental/Behavioral Health ER Physician Fee
YES

No Charge after deductible

No Charge after deductible
Mental/Behavioral Health Inpatient Services

Prior authorization may be required - please contact the number listed on your ID card.

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

Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization.

YES

No Charge after deductible

100.00%
Mental/Behavioral Health Urgent Care
YES

No Charge after deductible

100.00%
Multiple Sclerosis
YES

No Charge after deductible

100.00%
Naprapathic Service

Limit: 15.0 Visit(s) per Year

YES

No Charge after deductible

100.00%
Non-Preferred Brand Drugs
YES

No Charge after deductible

100.00%
Nutritional Counseling
YES

No Charge after deductible

100.00%
Organ Transplants
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%
Prescription Drugs Other
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 24/7 Care Visits received from Ambetter?s designated telehealth provider covered at No Charge, except for HSAs.

YES

No Charge after deductible

100.00%
Private-Duty Nursing

Available on an outpatient basis only (inpatient excluded)

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

1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality. 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer 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.

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

Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eye glasses.

YES

No Charge

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

No Charge

100.00%
Routine Foot Care
YES

No Charge after deductible

100.00%
Skilled Nursing Facility
YES

No Charge after deductible

100.00%
Specialist Visit
YES

No Charge after deductible

100.00%
Specialty Drugs
YES

No Charge after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Prior authorization may be required - please contact the number listed on your ID card.

YES

No Charge after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization.

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

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
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%
Tier 3 Generic Drugs

Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information.

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
YES

No Charge after deductible

100.00%
Urgent Care Centers or Facilities
YES

No Charge after deductible

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care

Covered in accordance with ACA guidelines.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

No Charge after deductible

100.00%

Clear Silver + Vision + Adult Dental Health Insurance Plan Variant 27833IL0150061-03 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 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Limited Cost Sharing Plan Variation
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 0.9675
First Tier Utilization 100%
Formulary ID ILF004
Formulary URL URL
HIOS Product ID 27833IL015
Import Date 2023-12-18 20:02:01
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 Actuarial Value 71.04%
Issuer ID 27833
Issuer Marketplace Marketing Name Ambetter of Illinois
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 ILN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 2024-01-01
Plan ID (Standard Component ID with Variant) 27833IL0150061-03
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 $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 $0
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 ILS001
Source Name SERFF
Plan ID 27833IL0150061
State Code IL
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, 27833IL0150061

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

Frequently Asked Questions(FAQ) about Clear Silver + Vision + Adult Dental, 27833IL0150061 Health Insurance Plan, 27833IL0150061

  • Does Clear Silver + Vision + Adult Dental Health Insurance Plan, 27833IL0150061 support Mail Ordering?

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

  • Does (27833IL0150061) Health Insurance Plan, Variant (27833IL0150061-03) offer Disease Management Programs?

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

    Does (27833IL0150061) Health Insurance Plan, Variant (27833IL0150061-03) have Out Of Country Coverage?

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

    Does (27833IL0150061) Health Insurance Plan, Variant (27833IL0150061-03) 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 (27833IL0150061) Health Insurance Plan, Variant (27833IL0150061-03) 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 (27833IL0150061-03) offer Disease Management Programs for Asthma?

    Yes, the Clear Silver + Vision + Adult Dental Health Insurance Plan Variant 27833IL0150061-03 offers Disease Management Program for Asthma.

    Does Clear Silver + Vision + Adult Dental Health Insurance Plan, Variant (27833IL0150061-03) offer Disease Management Programs for Heart disease?

    Yes, the Clear Silver + Vision + Adult Dental Health Insurance Plan Variant 27833IL0150061-03 offers Disease Management Program for Heart disease.

    Does Clear Silver + Vision + Adult Dental Health Insurance Plan, Variant (27833IL0150061-03) offer Disease Management Programs for Diabetes?

    Yes, the Clear Silver + Vision + Adult Dental Health Insurance Plan Variant 27833IL0150061-03 offers Disease Management Program for Diabetes.

    Does Clear Silver + Vision + Adult Dental Health Insurance Plan, Variant (27833IL0150061-03) offer Disease Management Programs for Pregnancy?

    Yes, the Clear Silver + Vision + Adult Dental Health Insurance Plan Variant 27833IL0150061-03 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