Blue Cross and Blue Shield of Nebraska health insurance plan with the Plan ID 29678NE1480009. The plan is called Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 BP.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.33% (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 12.67% 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 | 29678NE1480009 | ||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Health Insurance Plan Year | 2023 | ||||||||||||||||||
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 | 29678NE1480009-05 | ||||||||||||||||||
Provider Network(s) | ['NEN003'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT). |
|
||||||||||||||||||
Available Variants of the Health Plan | Standard Off Exchange Plan - 29678NE1480009-00 Standard On Exchange Plan - 29678NE1480009-01 Open to Indians below 300% FPL - 29678NE1480009-02 Open to Indians above 300% FPL - 29678NE1480009-03 73% AV Silver Plan - 29678NE1480009-04 |
||||||||||||||||||
Last Plan Update Date | Tue, 27 Sep 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
Assumption most services are in office |
YES | 15.00% Coinsurance after deductible |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Chemotherapy
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
Limit: 20.0 Visit(s) per Year |
YES | 15.00% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Dental Anesthesia
Based on most common prescription tier |
YES | 15.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | 15.00% Coinsurance after deductible |
100.00% |
Diabetes Care Management
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Diabetes Education
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Dialysis
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | 15.00% Coinsurance after deductible |
15.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
|
YES | 15.00% Coinsurance after deductible |
15.00% 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 | 15.00% Coinsurance after deductible |
100.00% |
Generic Drugs
|
YES | $5.00 |
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 | 15.00% Coinsurance after deductible |
100.00% |
Hearing Aids
covered up to age 19 limited to $3,000 every 48 months |
YES | 15.00% Coinsurance after deductible |
100.00% |
Home Health Care Services
Limit: 60.0 Days per Year |
YES | 15.00% 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 | 15.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Inpatient Services
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
|
YES | No Charge |
100.00% |
Non-Preferred Brand Drugs
|
YES | 55.00% Coinsurance after deductible |
100.00% |
Nutritional Counseling
Covered only for diabetes or ACA-required preventive care |
NO | ||
Off Label Prescription Drugs
|
YES | 15.00% 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 | 15.00% Coinsurance after deductible |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 15.00% 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 | 15.00% Coinsurance after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
|
YES | $150.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | $40.00 |
100.00% |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
|
YES | 15.00% 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 | 15.00% Coinsurance after deductible |
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 | 15.00% Coinsurance after deductible |
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 | 15.00% Coinsurance after deductible |
100.00% |
Routine Foot Care
|
NO | ||
Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | 15.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Specialty Drugs
|
YES | 60.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | No Charge |
100.00% |
Tier 2 Generic Drugs
|
YES | $20.00 |
100.00% |
Tier 2 Specialty Drugs
|
YES | 70.00% Coinsurance after deductible |
100.00% |
Transplant
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | $50.00 |
100.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | 15.00% Coinsurance after deductible |
100.00% |
X-rays and Diagnostic Imaging
|
YES | 15.00% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.873330509 |
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 | 87% AV Level Silver Plan |
Dental Only Plan | No |
Design Type | Not Applicable |
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 |
First Tier Utilization | 100% |
Formulary ID | NEF010 |
Formulary URL | URL |
HIOS Product ID | 29678NE148 |
Import Date | 9/27/2022 20:01 |
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 | 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 | Silver |
Multiple In Network Tiers | No |
National Network | No |
Network ID | NEN003 |
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 | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 29678NE1480009-05 |
Plan Marketing Name | Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 BP |
Plan Type | EPO |
Plan Variant Marketing Name | Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 BP |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $1,800 |
SBC Scenario, Having a Baby, Copayment | $10 |
SBC Scenario, Having a Baby, Deductible | $600 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $1,000 |
SBC Scenario, Having Diabetes, Deductible | $600 |
SBC Scenario, Having Diabetes, Limit | $70 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $300 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $10 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $600 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | NES001 |
Source Name | SERFF |
Plan ID | 29678NE1480009 |
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 | 15.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1200 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $600 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $600 |
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 | $6000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $3000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,000 |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
---|
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, 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