HeartlandBlue Gold Standard 1500 Premier Select BlueChoice - 29678NE1460013 Health Insurance Plan

Blue Cross and Blue Shield of Nebraska health insurance plan with the Plan ID 29678NE1460013. The plan is called HeartlandBlue Gold Standard 1500 Premier Select BlueChoice.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.02% (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 21.98% 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 29678NE1460013
Health Insurance Plan Year 2024
State Nebraska
Health Insurance Issuer Blue Cross and Blue Shield of Nebraska
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 29678NE1460013-00
Provider Network(s) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 02 Jul 2024 06:38 GMT).

Providers Nebraska All US States
All 17189 70964
PCP 1860 2250
Allergy 5 8
OB/GYN 56 76
Dentists 729 783
Available Variants of the Health Plan

Standard Off Exchange Plan - 29678NE1460013-00

Standard On Exchange Plan - 29678NE1460013-01

Open to Indians below 300% FPL - 29678NE1460013-02

Open to Indians above 300% FPL - 29678NE1460013-03

Last Plan Update Date Fri, 26 Jan 2024 00:00 GMT
Last Import Date Tue, 02 Jul 2024 06:38 GMT

Benefits of HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan, 29678NE1460013-00

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

25.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing

Assumption most services are in office

YES

25.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

25.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

25.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Dental Anesthesia

Based on most common prescription tier

YES

25.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

YES

25.00% Coinsurance after deductible

100.00%
Diabetes Care Management
YES

25.00% Coinsurance after deductible

100.00%
Diabetes Education
YES

25.00% Coinsurance after deductible

100.00%
Dialysis
YES

25.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

25.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

In-network deductible applies to both In and Out-Of-Network

YES

50.00% Coinsurance after deductible

100.00%
Gender Affirming Care
YES

25.00% Coinsurance after deductible

100.00%
Generic Drugs
YES

$15.00

100.00%
Habilitation Services

Limit: 45.0 Visit(s) per Year

The limit is 45 visits per year This limit is shared by Physical Occupational, Speech Therapy and Outpatient Habilitative Services

YES

25.00% Coinsurance after deductible

100.00%
Hearing Aids

covered up to age 19 limited to $3,000 every 48 months

YES

25.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Days per Year

YES

25.00% Coinsurance after deductible

100.00%
Hospice Services

The Covered Person must have a life expectancy of six months or less as documented in writing by the attending Physician. The Hospice Services must be ordered by a Physician. Services provided must be appropriate for palliative support or management of a Covered Person with terminal medical Illness.

YES

25.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

25.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

25.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

25.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

25.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$30.00

100.00%
Non-Preferred Brand Drugs
YES

$60.00

100.00%
Nutritional Counseling

Covered only for diabetes or ACA-required preventive care

NO
Off Label Prescription Drugs
YES

25.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

There is a 24 month waiting period for this benefit

YES

70.00% Coinsurance after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 45.0 Visit(s) per Year

The limit is 45 visits per year This limit is shared by Physical Occupational, Speech Therapy and Outpatient Rehabilitation

YES

25.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$30.00

100.00%
Prenatal and Postnatal Care
YES

25.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness

Unlimited telehealth/virtual care visits to the in-network doctor of your choice with $0 copay

YES

$30.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

25.00% Coinsurance after deductible

100.00%
Radiation
YES

25.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

25.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 45.0 Visit(s) per Year

The limit is 45 visits per year This limit is shared by Physical Occupational, Speech Therapy and Outpatient Rehabilitation

YES

$30.00

100.00%
Rehabilitative Speech Therapy

Limit: 45.0 Visit(s) per Year

The limit is 45 visits per year This limit is shared by Physical Occupational, Speech Therapy and Outpatient Rehabilitation

YES

$30.00

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

25.00% Coinsurance after deductible

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

25.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$60.00

100.00%
Specialty Drugs
YES

$250.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

25.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$30.00

100.00%
Transplant
YES

25.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

25.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$45.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

25.00% Coinsurance after deductible

100.00%
X-rays and Diagnostic Imaging
YES

25.00% Coinsurance after deductible

100.00%

HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan Variant 29678NE1460013-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7801851164396751
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Gold Off Exchange Plan
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID NEF012
Formulary URL URL
HIOS Product ID 29678NE146
Import Date 2024-01-26 20:01:59
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 No
Is a Referral Required for Specialist? No
Issuer ID 29678
Issuer Marketplace Marketing Name Blue Cross and Blue Shield of Nebraska
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID NEN002
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Services
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Services
Plan Brochure URL
Plan Effective Date 2024-01-01
Plan Expiration Date 2024-12-31
Plan ID (Standard Component ID with Variant) 29678NE1460013-00
Plan Marketing Name HeartlandBlue Gold Standard 1500 Premier Select BlueChoice
Plan Type EPO
Plan Variant Marketing Name HeartlandBlue Gold Standard 1500 Premier Select BlueChoice
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,700
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $1,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $800
SBC Scenario, Having Diabetes, Deductible $300
SBC Scenario, Having Diabetes, Limit $70
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $200
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID NES001
Source Name SERFF
Plan ID 29678NE1460013
State Code NE
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
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $3000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,500
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Out of 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 No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan, 29678NE1460013

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

Frequently Asked Questions(FAQ) about HeartlandBlue Gold Standard 1500 Premier Select BlueChoice, 29678NE1460013 Health Insurance Plan, 29678NE1460013

  • Does HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan, 29678NE1460013 support Mail Ordering?

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

  • Does (29678NE1460013) Health Insurance Plan, Variant (29678NE1460013-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does (29678NE1460013) Health Insurance Plan, Variant (29678NE1460013-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services

    Does (29678NE1460013) Health Insurance Plan, Variant (29678NE1460013-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services

    Does (29678NE1460013) Health Insurance Plan, Variant (29678NE1460013-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan, Variant (29678NE1460013-00) offer Disease Management Programs for Asthma?

    Yes, the HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan Variant 29678NE1460013-00 offers Disease Management Program for Asthma.

    Does HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan, Variant (29678NE1460013-00) offer Disease Management Programs for Heart disease?

    Yes, the HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan Variant 29678NE1460013-00 offers Disease Management Program for Heart disease.

    Does HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan, Variant (29678NE1460013-00) offer Disease Management Programs for Depression?

    Yes, the HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan Variant 29678NE1460013-00 offers Disease Management Program for Depression.

    Does HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan, Variant (29678NE1460013-00) offer Disease Management Programs for Diabetes?

    Yes, the HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan Variant 29678NE1460013-00 offers Disease Management Program for Diabetes.

    Does HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan, Variant (29678NE1460013-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan Variant 29678NE1460013-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan, Variant (29678NE1460013-00) offer Disease Management Programs for Low back pain?

    Yes, the HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan Variant 29678NE1460013-00 offers Disease Management Program for Low back pain.

    Does HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan, Variant (29678NE1460013-00) offer Disease Management Programs for Pregnancy?

    Yes, the HeartlandBlue Gold Standard 1500 Premier Select BlueChoice Health Insurance Plan Variant 29678NE1460013-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 02 Jul 2024 06:38 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