Elite Bronze + Vision + Adult Dental - 61604LA0020006 Health Insurance Plan

Louisiana Healthcare Connections Inc. health insurance plan with the Plan ID 61604LA0020006. The plan is called Elite Bronze + Vision + Adult Dental.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.65% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.35% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 61604LA0020006
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 61604LA0020006-00
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 - 61604LA0020006-00

Standard On Exchange Plan - 61604LA0020006-01

Open to Indians below 300% FPL - 61604LA0020006-02

Open to Indians above 300% FPL - 61604LA0020006-03

Last Plan Update Date Fri, 24 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, 61604LA0020006-00

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

High-dose chemotherapy to support transplant procedures.

YES

50.00%

100.00%
Chiropractic Care
YES

$80.00

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

$3,000.00

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

$115.00

100.00%
Dialysis
YES

50.00%

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

50.00%

100.00%
Emergency Room Services
YES

$2,500.00

$2,500.00
Emergency Transportation/Ambulance

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

YES

50.00%

50.00%
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

$3,000.00

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

$31.40

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

50.00%

100.00%
Hearing Aids

Limit: 2.0 Item(s) per 3 Years

YES

50.00%

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

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

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

NO
Infusion Therapy
YES

50.00%

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

$3,000.00 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

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

$1,250.00

$1,250.00
Mental/Behavioral Health Emergency Transportation/Ambulance
YES

$1,250.00

$1,250.00
Mental/Behavioral Health ER Physician Fee
YES

$1,250.00

$1,250.00
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

$3,000.00 Copay per Day

100.00%
Mental/Behavioral Health Outpatient Other Services
YES

50.00%

100.00%
Mental/Behavioral Health Outpatient Services
YES

$45.00

100.00%
Mental/Behavioral Health Urgent Care
YES

$60.00

100.00%
Non-Preferred Brand Drugs
YES

$250.00 Copay after deductible

100.00%
Nutritional Counseling

Coverage only for diabetes education.

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
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
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

$45.00

100.00%
Private-Duty Nursing
YES

$3,000.00

100.00%
Prosthetic Devices
YES

50.00%

100.00%
Radiation
YES

50.00%

100.00%
Reconstructive Surgery

Breast Reconstructive Surgery Services.

YES

$3,000.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

50.00%

100.00%
Rehabilitative Speech Therapy
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)

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

$3,000.00 Copay per Day

100.00%
Specialist Visit
YES

$115.00

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

50.00% Coinsurance 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

$3,000.00 Copay per Day

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

$45.00

100.00%
Substance Use Disorder Emergency Room
YES

$1,250.00

$1,250.00
Substance Use Disorder Emergency Transportation/Ambulance
YES

$1,250.00

$1,250.00
Substance Use Disorder ER Physician Fee
YES

$1,250.00

$1,250.00
Substance Use Disorder Outpatient Other Services
YES

50.00%

100.00%
Substance Use Disorder Urgent Care
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
NO
Urgent Care Centers or Facilities
YES

$60.00

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

50.00%

100.00%

Elite Bronze + Vision + Adult Dental Health Insurance Plan Variant 61604LA0020006-00 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 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 0.964
First Tier Utilization 100%
Formulary ID LAF003
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 Existing
Notice Required for Pregnancy Yes
Is a Referral Required for Specialist? No
Issuer Actuarial Value 64.65%
Issuer ID 61604
Issuer Marketplace Marketing Name Ambetter from Louisiana Healthcare Connections
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 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) 61604LA0020006-00
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 LAS001
Source Name HIOS
Plan ID 61604LA0020006
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
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

Copay & Coinsurance of Elite Bronze + Vision + Adult Dental Health Insurance Plan, 61604LA0020006

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

Frequently Asked Questions(FAQ) about Elite Bronze + Vision + Adult Dental, 61604LA0020006 Health Insurance Plan, 61604LA0020006

  • Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, 61604LA0020006 support Mail Ordering?

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

  • Does (61604LA0020006) Health Insurance Plan, Variant (61604LA0020006-00) offer Disease Management Programs?

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

    Does (61604LA0020006) Health Insurance Plan, Variant (61604LA0020006-00) have Out Of Country Coverage?

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

    Does (61604LA0020006) Health Insurance Plan, Variant (61604LA0020006-00) 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 (61604LA0020006) Health Insurance Plan, Variant (61604LA0020006-00) offer Disease Management Programs?

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

    Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, Variant (61604LA0020006-00) offer Disease Management Programs for Asthma?

    Yes, the Elite Bronze + Vision + Adult Dental Health Insurance Plan Variant 61604LA0020006-00 offers Disease Management Program for Asthma.

    Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, Variant (61604LA0020006-00) offer Disease Management Programs for Heart disease?

    Yes, the Elite Bronze + Vision + Adult Dental Health Insurance Plan Variant 61604LA0020006-00 offers Disease Management Program for Heart disease.

    Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, Variant (61604LA0020006-00) offer Disease Management Programs for Diabetes?

    Yes, the Elite Bronze + Vision + Adult Dental Health Insurance Plan Variant 61604LA0020006-00 offers Disease Management Program for Diabetes.

    Does Elite Bronze + Vision + Adult Dental Health Insurance Plan, Variant (61604LA0020006-00) offer Disease Management Programs for Pregnancy?

    Yes, the Elite Bronze + Vision + Adult Dental Health Insurance Plan Variant 61604LA0020006-00 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