Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC - 29678NE1470009 Health Insurance Plan

Blue Cross and Blue Shield of Nebraska health insurance plan with the Plan ID 29678NE1470009. The plan is called Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 29678NE1470009
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 29678NE1470009-02
Provider Network(s) ['NEN002']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Feb 2024 05:55 GMT).

Providers Nebraska 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 - 29678NE1470009-00

Standard On Exchange Plan - 29678NE1470009-01

Open to Indians below 300% FPL - 29678NE1470009-02

Open to Indians above 300% FPL - 29678NE1470009-03

73% AV Silver Plan - 29678NE1470009-04

87% AV Silver Plan - 29678NE1470009-05

94% AV Silver Plan - 29678NE1470009-06

Last Plan Update Date Tue, 27 Sep 2022 00:00 GMT
Last Import Date Tue, 20 Feb 2024 05:55 GMT

Benefits of Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan, 29678NE1470009-02

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

$0.00, 0.00%

100.00%
Acupuncture
NO
Allergy Testing

Assumption most services are in office

YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Chemotherapy
YES

$0.00, 0.00%

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Dental Anesthesia

Based on most common prescription tier

YES

$0.00, 0.00%

100.00%
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

YES

$0.00, 0.00%

100.00%
Diabetes Care Management
YES

$0.00, 0.00%

100.00%
Diabetes Education
YES

$0.00, 0.00%

100.00%
Dialysis
YES

$0.00, 0.00%

100.00%
Durable Medical Equipment
YES

$0.00, 0.00%

100.00%
Emergency Room Services
YES

$0.00, 0.00%

0.00%
Emergency Transportation/Ambulance
YES

$0.00, 0.00%

0.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

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

YES

$0.00, 0.00%

100.00%
Gender Affirming Care
YES

$0.00, 0.00%

100.00%
Generic Drugs
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Hearing Aids

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

YES

$0.00, 0.00%

100.00%
Home Health Care Services

Limit: 60.0 Days per Year

YES

$0.00, 0.00%

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

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Inpatient Physician and Surgical Services
YES

$0.00, 0.00%

100.00%
Laboratory Outpatient and Professional Services
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Mental/Behavioral Health Inpatient Services
YES

$0.00, 0.00%

100.00%
Mental/Behavioral Health Outpatient Services
YES

$0.00, 0.00%

100.00%
Non-Preferred Brand Drugs
YES

$0.00, 0.00%

100.00%
Nutritional Counseling

Covered only for diabetes or ACA-required preventive care

NO
Off Label Prescription Drugs
YES

$0.00, 0.00%

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

There is a 24 month waiting period for this benefit

YES

$0.00, 0.00%

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

$0.00, 0.00%

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

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$0.00, 0.00%

100.00%
Preferred Brand Drugs
YES

$0.00, 0.00%

100.00%
Prenatal and Postnatal Care
YES

$0.00, 0.00%

100.00%
Preventive Care/Screening/Immunization
YES

$0.00, 0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$0.00, 0.00%

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

$0.00, 0.00%

100.00%
Radiation
YES

$0.00, 0.00%

100.00%
Reconstructive Surgery
YES

$0.00, 0.00%

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

$0.00, 0.00%

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

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

$0.00, 0.00%

100.00%
Specialist Visit
YES

$0.00, 0.00%

100.00%
Specialty Drugs
YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Outpatient Services
YES

$0.00, 0.00%

100.00%
Tier 2 Generic Drugs
YES

$0.00, 0.00%

100.00%
Tier 2 Specialty Drugs
YES

$0.00, 0.00%

100.00%
Transplant
YES

$0.00, 0.00%

100.00%
Treatment for Temporomandibular Joint Disorders
YES

$0.00, 0.00%

100.00%
Urgent Care Centers or Facilities
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
X-rays and Diagnostic Imaging
YES

$0.00, 0.00%

100.00%

Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan Variant 29678NE1470009-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1
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 Zero Cost Sharing Plan Variation
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 29678NE147
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 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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 29678NE1470009-02
Plan Marketing Name Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC
Plan Type EPO
Plan Variant Marketing Name Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID NES002
Source Name SERFF
Plan ID 29678NE1470009
State Code NE
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $0
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $0
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $0
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $0
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan, 29678NE1470009

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

Frequently Asked Questions(FAQ) about Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC, 29678NE1470009 Health Insurance Plan, 29678NE1470009

  • Does Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan, 29678NE1470009 support Mail Ordering?

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

  • Does (29678NE1470009) Health Insurance Plan, Variant (29678NE1470009-02) 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 (29678NE1470009) Health Insurance Plan, Variant (29678NE1470009-02) have Out Of Country Coverage?

    Yes. Details: Emergency Services

    Does (29678NE1470009) Health Insurance Plan, Variant (29678NE1470009-02) have Out of Service Area Coverage?

    Yes. Details: Emergency Services

    Does (29678NE1470009) Health Insurance Plan, Variant (29678NE1470009-02) 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 Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan, Variant (29678NE1470009-02) offer Disease Management Programs for Asthma?

    Yes, the Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan Variant 29678NE1470009-02 offers Disease Management Program for Asthma.

    Does Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan, Variant (29678NE1470009-02) offer Disease Management Programs for Heart disease?

    Yes, the Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan Variant 29678NE1470009-02 offers Disease Management Program for Heart disease.

    Does Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan, Variant (29678NE1470009-02) offer Disease Management Programs for Depression?

    Yes, the Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan Variant 29678NE1470009-02 offers Disease Management Program for Depression.

    Does Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan, Variant (29678NE1470009-02) offer Disease Management Programs for Diabetes?

    Yes, the Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan Variant 29678NE1470009-02 offers Disease Management Program for Diabetes.

    Does Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan, Variant (29678NE1470009-02) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan Variant 29678NE1470009-02 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan, Variant (29678NE1470009-02) offer Disease Management Programs for Low back pain?

    Yes, the Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan Variant 29678NE1470009-02 offers Disease Management Program for Low back pain.

    Does Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan, Variant (29678NE1470009-02) offer Disease Management Programs for Pregnancy?

    Yes, the Nebraska HeartlandBlue Silver $0 Mental Health Visit 6000 PSBC Health Insurance Plan Variant 29678NE1470009-02 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 20 Feb 2024 05:55 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