Elite Bronze + Vision + Adult Dental - 27833IL0150054 Health Insurance Plan
Celtic Insurance Company health insurance plan with the Plan ID 27833IL0150054. The plan is called Elite Bronze + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 100.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 27833IL0150054 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Illinois | ||||||||||||||||||
| Health Insurance Issuer | Celtic Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 27833IL0150054-02 | ||||||||||||||||||
| Provider Network(s) | ['ILN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 27833IL0150054-00 Standard On Exchange Plan - 27833IL0150054-01 |
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| Last Plan Update Date | Thu, 23 Feb 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
Benefits of Elite Bronze + Vision + Adult Dental Health Insurance Plan, 27833IL0150054-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | $0.00, 0.00% |
100.00% |
| Accidental Dental
|
YES | $0.00, 0.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $0.00, 0.00% |
100.00% |
| Autism Spectrum Disorders
|
YES | $0.00, 0.00% |
100.00% |
| Bariatric Surgery
|
YES | $0.00, 0.00% |
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; Excluded from the In-Network MOOP |
YES | 50.00% |
100.00% |
| Basic Dental Care - Child
|
NO | ||
| Bones/Joints
|
YES | $0.00, 0.00% |
100.00% |
| Breast Implant Removal
|
YES | $0.00, 0.00% |
100.00% |
| Cardiac Rehabilitation
|
YES | $0.00, 0.00% |
100.00% |
| Chemotherapy
|
YES | $0.00, 0.00% |
100.00% |
| Chiropractic Care
Limit: 25.0 Visit(s) per Year |
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | $0.00, 0.00% |
100.00% |
| Dental Anesthesia
|
YES | $0.00, 0.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $0.00, 0.00% |
100.00% |
| Dialysis
|
YES | $0.00, 0.00% |
100.00% |
| Durable Medical Equipment
|
YES | $0.00, 0.00% |
100.00% |
| Emergency Room Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Eyeglasses for Adults
Limit: 1.0 Item(s) per Year Covered up to $130; Excluded from In-Network MOOP |
YES | No Charge |
100.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Habilitation Services
|
YES | $0.00, 0.00% |
100.00% |
| Hearing Aids
Limit: 2.0 Item(s) per 2 Years |
YES | $0.00, 0.00% |
100.00% |
| Home Health Care Services
|
YES | $0.00, 0.00% |
100.00% |
| Hospice Services
|
YES | $0.00, 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Cost share is based on place of service. |
YES | $0.00, 0.00% |
100.00% |
| Infertility Treatment
|
YES | $0.00, 0.00% |
100.00% |
| Infusion Therapy
|
YES | $0.00, 0.00% |
100.00% |
| Inherited Metabolic Disorder - PKU
|
YES | $0.00, 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $0.00, 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $0.00, 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
Cost share is based on place of service. |
YES | $0.00, 0.00% |
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; Excluded from the In-Network MOOP |
YES | 50.00% |
100.00% |
| Major Dental Care - Child
Limitations vary based on procedures. |
NO | ||
| Mental/Behavioral Health Emergency Room
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Mental/Behavioral Health Emergency Transportation/Ambulance
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Mental/Behavioral Health ER Physician Fee
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
|
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Urgent Care
|
YES | $0.00, 0.00% |
100.00% |
| Multiple Sclerosis
|
YES | $0.00, 0.00% |
100.00% |
| Naprapathic Service
Limit: 15.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Nutritional Counseling
|
YES | $0.00, 0.00% |
100.00% |
| Organ Transplants
|
YES | $0.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Limitations vary based on procedures. |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00, 0.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $0.00, 0.00% |
100.00% |
| Outpatient Rehabilitation Services
|
YES | $0.00, 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $0.00, 0.00% |
100.00% |
| Preferred Brand Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Prenatal and Postnatal Care
|
YES | $0.00, 0.00% |
100.00% |
| Prescription Drugs Other
|
YES | $0.00, 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | $0.00, 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs. |
YES | $0.00, 0.00% |
100.00% |
| Private-Duty Nursing
Available on an outpatient basis only (inpatient excluded) |
YES | $0.00, 0.00% |
100.00% |
| Prosthetic Devices
|
YES | $0.00, 0.00% |
100.00% |
| Radiation
|
YES | $0.00, 0.00% |
100.00% |
| Reconstructive Surgery
|
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Speech Therapy
|
YES | $0.00, 0.00% |
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; Excluded from the In-Network MOOP |
YES | $0.00, 0.00% |
100.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Year Excluded from In Network MOOP |
YES | $0.00, 0.00% |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Routine Foot Care
Prior authorization may be required. Covered no limit. |
YES | $0.00, 0.00% |
100.00% |
| Skilled Nursing Facility
|
YES | $0.00, 0.00% |
100.00% |
| Specialist Visit
|
YES | $0.00, 0.00% |
100.00% |
| Specialty Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Substance Use Disorder Emergency Room
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Substance Use Disorder Emergency Transportation/Ambulance
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Substance Use Disorder ER Physician Fee
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Substance Use Disorder Outpatient Other Services
|
YES | $0.00, 0.00% |
100.00% |
| Substance Use Disorder Urgent Care
|
YES | $0.00, 0.00% |
100.00% |
| Transplant
Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | $0.00, 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | $0.00, 0.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $0.00, 0.00% |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | $0.00, 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
Cost share is based on place of service. |
YES | $0.00, 0.00% |
100.00% |
Elite Bronze + Vision + Adult Dental Health Insurance Plan Variant 27833IL0150054-02 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 | Zero Cost Sharing Plan Variation |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 0.9612 |
| First Tier Utilization | 100% |
| Formulary ID | ILF007 |
| Formulary URL | URL |
| HIOS Product ID | 27833IL015 |
| Import Date | 2/23/2023 20:01 |
| 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? | Yes |
| Issuer Actuarial Value | 100.00% |
| Issuer ID | 27833 |
| Issuer Marketplace Marketing Name | Ambetter of Illinois |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Expanded Bronze |
| 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 | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 27833IL0150054-02 |
| Plan Marketing Name | Elite Bronze + Vision + Adult Dental |
| Plan Type | HMO |
| Plan Variant Marketing Name | Elite Bronze + 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 |
| Specialist Requiring a Referral | All except for mental or behavioral health services, obstetrical or gynecological treatment. |
| Plan ID | 27833IL0150054 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| 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 Elite Bronze + Vision + Adult Dental Health Insurance Plan, 27833IL0150054
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Elite Bronze + Vision + Adult Dental, 27833IL0150054 Health Insurance Plan, 27833IL0150054
-
Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, 27833IL0150054 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (27833IL0150054) Health Insurance Plan, Variant (27833IL0150054-02) offer Disease Management Programs?
Does (27833IL0150054) Health Insurance Plan, Variant (27833IL0150054-02) have Out Of Country Coverage?
Does (27833IL0150054) Health Insurance Plan, Variant (27833IL0150054-02) have Out of Service Area Coverage?
Does (27833IL0150054) Health Insurance Plan, Variant (27833IL0150054-02) offer Disease Management Programs?
Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, Variant (27833IL0150054-02) offer Disease Management Programs for Asthma?
Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, Variant (27833IL0150054-02) offer Disease Management Programs for Heart disease?
Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, Variant (27833IL0150054-02) offer Disease Management Programs for Diabetes?
Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, Variant (27833IL0150054-02) offer Disease Management Programs 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