Celtic Insurance Company health insurance plan with the Plan ID 70111TN0150001. The plan is called Elite SELECT Bronze with Select Providers.
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).
Health Insurance Plan ID | 70111TN0150001 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Tennessee | ||||||||||||||||||
Health Insurance Issuer | Celtic Insurance Company | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 70111TN0150001-00 | ||||||||||||||||||
Provider Network(s) | ['TNN002'] | ||||||||||||||||||
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 - 70111TN0150001-00 Standard On Exchange Plan - 70111TN0150001-01 |
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Last Plan Update Date | Fri, 24 Feb 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
|
YES | 50.00% |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | $115.00 |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Chemotherapy
|
YES | 50.00% |
100.00% |
Chiropractic Care
Limit: 20.0 Visit(s) per Year |
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
|
YES | $115.00 |
100.00% |
Dialysis
|
YES | 50.00% |
100.00% |
Durable Medical Equipment
|
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% |
Eye Glasses for Children
Limit: 1.0 Visit(s) per Year |
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
Limit: 20.0 Visit(s) per Year Limited to 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy); Limited to 36 visits per year per therapy for cardiac and pulmonary therapy. |
YES | 50.00% |
100.00% |
Hearing Aids
Limit: 2.0 Item(s) per 3 Years |
YES | 50.00% |
100.00% |
Home Health Care Services
Limit: 60.0 Visit(s) per Year |
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
Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency) |
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
|
NO | ||
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
|
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
For Diabetes Treatment only. |
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: 20.0 Visit(s) per Year Limited to 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy); Limited to 36 visits per year per therapy for cardiac and pulmonary therapy. |
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
Covered in accordance with ACA guidelines. |
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
|
NO | ||
Prosthetic Devices
|
YES | 50.00% |
100.00% |
Radiation
|
YES | 50.00% |
100.00% |
Reconstructive Surgery
Covered Services: Surgery to correct significant defects from congenital causes, (except where specifically excluded), accidents or disfigurement from a disease state. Reconstructive breast Surgery as a result of a mastectomy or partial mastectomy (other than lumpectomy). |
YES | $3,000.00 |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Limited to 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy); Limited to 36 visits per year per therapy for cardiac and pulmonary therapy. |
YES | 50.00% |
100.00% |
Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Limited to 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy); Limited to 36 visits per year per therapy for cardiac and pulmonary therapy. |
YES | 50.00% |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
Routine Foot Care
Coverage is limited to diabetes care only. |
NO | ||
Skilled Nursing Facility
Limit: 60.0 Days per Year Skilled Nursing and Rehabilitation Facility limited to 60 days/year combined. |
YES | $3,000.00 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
|
YES | $3,000.00 Copay per Day |
100.00% |
Substance Abuse Disorder Outpatient Services
|
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
|
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 |
---|---|
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 | 1 |
First Tier Utilization | 100% |
Formulary ID | TNF007 |
Formulary URL | URL |
HIOS Product ID | 70111TN015 |
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 | 64.66% |
Issuer ID | 70111 |
Issuer Marketplace Marketing Name | Ambetter of Tennessee |
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 | TNN002 |
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) | 70111TN0150001-00 |
Plan Marketing Name | Elite SELECT Bronze with Select Providers |
Plan Type | EPO |
Plan Variant Marketing Name | Elite SELECT Bronze with Select Providers |
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 | TNS002 |
Source Name | HIOS |
Plan ID | 70111TN0150001 |
State Code | TN |
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