Elite VALUE Bronze - 86382FL0050005 Health Insurance Plan

Sunshine State Health Plan health insurance plan with the Plan ID 86382FL0050005. The plan is called Elite VALUE Bronze.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.72% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.28% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 86382FL0050005
Health Insurance Plan Year 2025
State Florida
Health Insurance Issuer Sunshine State Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 86382FL0050005-00
Provider Network(s) ['FLN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Florida 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 - 86382FL0050005-00

Standard On Exchange Plan - 86382FL0050005-01

Open to Indians below 300% FPL - 86382FL0050005-02

Open to Indians above 300% FPL - 86382FL0050005-03

Last Plan Update Date Wed, 14 Aug 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Elite VALUE Bronze Health Insurance Plan, 86382FL0050005-00

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
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

50.00%

100.00%
Chiropractic Care

Limit: 35.0 Visit(s) per Year

Limited to a combined 35 visits per year, including outpatient therapy.

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

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 Item(s) per Year

YES

No Charge

100.00%
Gender Affirming Care
YES

$3,000.00

100.00%
Generic Drugs

Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-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

$3.00

100.00%
Habilitation Services

Limit: 35.0 Visit(s) per Year

Outpatient rehabilitation therapy is limited to a combined 35 visits per year, including chiropractic care.

YES

50.00%

100.00%
Hearing Aids

Cochlear Implants and Bone Anchored Hearing Aids are not a covered benefit.

NO
Home Health Care Services

Limit: 20.0 Visit(s) per Year

YES

50.00%

100.00%
Hospice Services

Respite Care is covered as part of hospice services only.

YES

50.00%

100.00%
Imaging (CT/PET Scans, MRIs)
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
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

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

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

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

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

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

$60.00

100.00%
Mental/Behavioral Health Urgent Care
YES

$50.00

100.00%
Non-Preferred Brand Drugs
YES

45.00% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

$115.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$60.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

50.00%

100.00%
Outpatient Rehabilitation Services

Limit: 35.0 Visit(s) per Year

Outpatient rehabilitation therapy is limited to a combined 35 visits per year, including chiropractic care.

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

$60.00

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 24/7 Care Visits received from Ambetter?s designated telehealth provider covered at No Charge, except for HSAs.

YES

$60.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

50.00%

100.00%
Radiation
YES

50.00%

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

YES

$3,000.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 35.0 Visit(s) per Year

Outpatient rehabilitation therapy is limited to a combined 35 visits per year, including chiropractic care.

YES

50.00%

100.00%
Rehabilitative Speech Therapy

Limit: 35.0 Visit(s) per Year

Outpatient rehabilitation therapy is limited to a combined 35 visits per year, including chiropractic care.

YES

50.00%

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

No Charge

100.00%
Routine Foot Care
YES

$115.00

100.00%
Skilled Nursing Facility

Limit: 60.0 Days per Year

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

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

YES

$3,000.00 Copay per Day

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

$60.00

100.00%
Substance Use Disorder Emergency Room
YES

$1,250.00

$1,250.00
Substance Use Disorder Emergency Transportation/Ambulance

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

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

$50.00

100.00%
Tier 1b 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

$35.00

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
YES

50.00%

100.00%

Elite VALUE Bronze Health Insurance Plan Variant 86382FL0050005-00 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 2025
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 1.0
First Tier Utilization 100%
Formulary ID FLF001
Formulary URL URL
HIOS Product ID 86382FL005
Import Date 2024-08-14 01:01:35
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 64.72%
Issuer ID 86382
Issuer Marketplace Marketing Name Ambetter Health
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 FLN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan ID (Standard Component ID with Variant) 86382FL0050005-00
Plan Marketing Name Elite VALUE Bronze
Plan Type HMO
Plan Variant Marketing Name Elite VALUE Bronze
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 $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $400
SBC Scenario, Having Diabetes, Copayment $3,500
SBC Scenario, Having Diabetes, Deductible $0
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 $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID FLS001
Source Name HIOS
Specialist Requiring a Referral All except for mental or behavioral health services, obstetrical or gynecological treatment
Plan ID 86382FL0050005
State Code FL
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 $18400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9200 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,200
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 VALUE Bronze Health Insurance Plan, 86382FL0050005

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

Frequently Asked Questions(FAQ) about Elite VALUE Bronze, 86382FL0050005 Health Insurance Plan, 86382FL0050005

  • Does Elite VALUE Bronze Health Insurance Plan, 86382FL0050005 support Mail Ordering?

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

  • Does (86382FL0050005) Health Insurance Plan, Variant (86382FL0050005-00) offer Disease Management Programs?

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

    Does (86382FL0050005) Health Insurance Plan, Variant (86382FL0050005-00) have Out Of Country Coverage?

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

    Does (86382FL0050005) Health Insurance Plan, Variant (86382FL0050005-00) 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 (86382FL0050005) Health Insurance Plan, Variant (86382FL0050005-00) offer Disease Management Programs?

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

    Does Elite VALUE Bronze Health Insurance Plan, Variant (86382FL0050005-00) offer Disease Management Programs for Asthma?

    Yes, the Elite VALUE Bronze Health Insurance Plan Variant 86382FL0050005-00 offers Disease Management Program for Asthma.

    Does Elite VALUE Bronze Health Insurance Plan, Variant (86382FL0050005-00) offer Disease Management Programs for Heart disease?

    Yes, the Elite VALUE Bronze Health Insurance Plan Variant 86382FL0050005-00 offers Disease Management Program for Heart disease.

    Does Elite VALUE Bronze Health Insurance Plan, Variant (86382FL0050005-00) offer Disease Management Programs for Diabetes?

    Yes, the Elite VALUE Bronze Health Insurance Plan Variant 86382FL0050005-00 offers Disease Management Program for Diabetes.

    Does Elite VALUE Bronze Health Insurance Plan, Variant (86382FL0050005-00) offer Disease Management Programs for Pregnancy?

    Yes, the Elite VALUE Bronze Health Insurance Plan Variant 86382FL0050005-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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