Buckeye Community Health Plan health insurance plan with the Plan ID 41047OH0030060. The plan is called Elite Bronze + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.66% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.34% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 66.31% (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 33.69% 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 | 41047OH0030060 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Ohio | ||||||||||||||||||
Health Insurance Issuer | Buckeye Community Health Plan | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 41047OH0030060-00 | ||||||||||||||||||
Provider Network(s) | ['OHN001'] | ||||||||||||||||||
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 - 41047OH0030060-00 Standard On Exchange Plan - 41047OH0030060-01 |
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Last Plan Update Date | Wed, 25 Jan 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
Limit: 3000.0 Dollars per Episode Limited to $3,000 per occurrence. Quantitative Limit represents established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply. Coverage for dental services resulting from an accidental injury when treatment is performed within 12 months after the injury. The benefit limit will not apply to outpatient facility charges, anesthesia billed by a provider other than the physician performing the service, or to covered services required by law; coverage includes oral examinations, x-rays, tests and laboratory examinations, restorations, prosthetic services, oral surgery, mandibular/maxillary reconstruction, anesthesia and include facility charges for outpatient services for the removal of teeth or for other dental processes if the patient?s medical condition or the dental procedure requires a hospital setting to ensure the safety of the patient. |
YES | 50.00% |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | $115.00 |
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
|
YES | 50.00% |
100.00% |
Chiropractic Care
Limit: 12.0 Visit(s) per Year Limited to 12 visits per year. Benefit limit applies for Osteopathic/Chiropractic Manipulation Therapy. |
YES | $80.00 |
100.00% |
Cosmetic Surgery
"Directly related means that the treatment or surgery occurred as a direct result of, and would not have taken place in the absence of, the cosmetic surgery. This exclusion does not apply to conditions including but not limited to: myocardial infarction; pulmonary embolism, thrombophlebitis, and exacerbation of co-morbid conditions during the procedure or in the immediate post-operative time frame." |
NO | ||
Delivery and All Inpatient Services for Maternity Care
Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Prenatal Care. |
YES | $3,000.00 |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Education
|
YES | $115.00 |
100.00% |
Dialysis
Benefits include supportive use of an artificial kidney machine. |
YES | 50.00% |
100.00% |
Durable Medical Equipment
|
YES | 50.00% |
100.00% |
Emergency Room Services
|
YES | $1,250.00 |
$1,250.00 |
Emergency Transportation/Ambulance
|
YES | 50.00% |
50.00% |
ER Diagnostic Test Lab-work/Other
|
YES | $60.00 |
$60.00 |
ER Diagnostic Test (X-Ray)
|
YES | 50.00% |
50.00% |
ER Imaging Test
|
YES | 50.00% |
No Charge, 50.00% |
ER Physician Fee
|
YES | $1,250.00 |
$1,250.00 |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits. |
YES | No Charge |
100.00% |
Gender Affirming Care
|
YES | $3,000.00 |
100.00% |
Generic Drugs
Most Ambetter Plans offer Preferred Generic Drugs at $5 or less. |
YES | $31.40 |
100.00% |
Habilitation Services
|
YES | 50.00% |
100.00% |
Hearing Aids
|
NO | ||
Home Health Care Services
Limit: 100.0 Visit(s) per Year When therapy services are provided in the home (including physical, speech, and occupational therapy) as part of home health care services, they are not subject to separate visit limits for therapy services. The 100 visit/year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting. |
YES | 50.00% |
100.00% |
Hospice Services
|
YES | 50.00% |
100.00% |
Imaging (CT/PET Scans, MRIs)
Cost share is based on place of service. |
YES | 50.00% |
100.00% |
Infertility Treatment
Infertility and voluntary family planning services are required benefits under state law for HMO plans only per ORC section 1751.01 (A)(1)(h), and must be provided in accordance with Ohio Department of Insurance Bulletin No. 2009-07. For the diagnosis and treatment of medical condition causing infertility, Not covered ? in vitro (IVF), GIFT or ZIFT. |
YES | 50.00% |
100.00% |
Infusion Therapy
|
YES | 50.00% |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services; and ancillary (related) services. 60 visits/year for Inpatient Rehabilitation Services |
YES | $3000.00 Copay per Day |
100.00% |
Inpatient Physician and Surgical Services
|
YES | No Charge |
100.00% |
Laboratory Outpatient and Professional Services
Cost share is based on place of service. |
YES | $60.00 |
100.00% |
Long-Term/Custodial Nursing Home Care
|
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
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $1,250.00 |
$1,250.00 |
Mental/Behavioral Health Emergency Transportation/Ambulance
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $1,250.00 |
$1,250.00 |
Mental/Behavioral Health ER Physician Fee
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $1,250.00 |
$1,250.00 |
Mental/Behavioral Health Inpatient Services
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $3000.00 Copay per Day |
100.00% |
Mental/Behavioral Health Outpatient Other Services
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | 50.00% |
100.00% |
Mental/Behavioral Health Outpatient Services
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $45.00 |
100.00% |
Mental/Behavioral Health Urgent Care
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $60.00 |
100.00% |
Non-Preferred Brand Drugs
|
YES | $250.00 Copay after deductible |
100.00% |
Nutritional Counseling
Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services (includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors). |
YES | $115.00 |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $45.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% |
100.00% |
Outpatient Rehabilitation Services
Limit: 116.0 Visit(s) per Year Therapy Services rendered in the home as part of Home Care Services will be subject to the Home Care Services visit limits; outpatient rehabilitation services visit limits will not apply. If different types of Therapy Services are performed during one Physician Home Visit, Office Service, or Outpatient Service, then each different type of Therapy Service performed will be considered a separate Therapy Visit. Each Therapy Visit will count against the applicable maximum visits per Benefit Period listed below: Physical, Occupational and Speech Therapy limited to 20 visits each. Cardiac Rehabilitation limited to 36 visits. Pulmonary Rehabilitation limited to 20 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply. Benefit also includes Physical Medicine and Rehabilitation Day Rehabilitation Therapy services on an Outpatient basis. Services may be used for Intensive Day Rehabilitation. |
YES | 50.00% |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% |
100.00% |
Preferred Brand Drugs
|
YES | $195.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | $45.00 |
100.00% |
Preventive Care/Screening/Immunization
Services with an 'A' or 'B' rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration. |
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, except for HSAs. |
YES | $45.00 |
100.00% |
Private-Duty Nursing
Limit: 90.0 Visit(s) per Year |
YES | $3,000.00 |
100.00% |
Prosthetic Devices
Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Limited to 4 mastecomy bras per year. Limited to 1 wig per year. |
YES | 50.00% |
100.00% |
Radiation
|
YES | 50.00% |
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 | $3,000.00 |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year 20 visits/year each for Physical & Occupational |
YES | 50.00% |
100.00% |
Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year 20 visits/year for Speech |
YES | 50.00% |
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 |
YES | No Charge |
100.00% |
Routine Eye Exam (Adult)
|
YES | No Charge |
100.00% |
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits. |
YES | No Charge |
100.00% |
Routine Foot Care
Coverage is limited to diabetes care only. |
NO | ||
Skilled Nursing Facility
Limit: 90.0 Days per Year All medically necessary Basic Health Care services must be covered by an HMO plan. Complications from a non-covered procedure that require the need for any medically necessary Basic Health Care Service must be covered same as any other services." |
YES | $3000.00 Copay per Day |
100.00% |
Specialist Visit
|
YES | $115.00 |
100.00% |
Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $3000.00 Copay per Day |
100.00% |
Substance Abuse Disorder Outpatient Services
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $45.00 |
100.00% |
Substance Use Disorder Emergency Room
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $1,250.00 |
$1,250.00 |
Substance Use Disorder Emergency Transportation/Ambulance
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $1,250.00 |
$1,250.00 |
Substance Use Disorder ER Physician Fee
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $1,250.00 |
$1,250.00 |
Substance Use Disorder Outpatient Other Services
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | 50.00% |
100.00% |
Substance Use Disorder Urgent Care
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $60.00 |
100.00% |
Transplant
Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | $3,000.00 |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% |
100.00% |
Urgent Care Centers or Facilities
|
YES | $60.00 |
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
Cost share is based on place of service. |
YES | 50.00% |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.663080399 |
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 Bronze Off Exchange Plan |
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 | 50.00% |
Drug EHB Deductible, In Network (Tier 1), Family Per Group | $7600 per group |
Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3800 per person |
Drug EHB Deductible, In Network (Tier 1), Individual | $3,800 |
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 | 0.968 |
First Tier Utilization | 100% |
Formulary ID | OHF007 |
Formulary URL | URL |
HIOS Product ID | 41047OH003 |
Import Date | 1/25/2023 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? | No |
Issuer Actuarial Value | 64.66% |
Issuer ID | 41047 |
Issuer Marketplace Marketing Name | Ambetter from Buckeye Health Plan |
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 | 50.00% |
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 | OHN001 |
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) | 41047OH0030060-00 |
Plan Level Exclusions | No |
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 | $200 |
SBC Scenario, Having a Baby, Copayment | $3,600 |
SBC Scenario, Having a Baby, Deductible | $10 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $400 |
SBC Scenario, Having Diabetes, Copayment | $700 |
SBC Scenario, Having Diabetes, Deductible | $3,500 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $800 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,100 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $10 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | OHS001 |
Source Name | SERFF |
Plan ID | 41047OH0030060 |
State Code | OH |
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 | $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 | Yes |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
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