Premier Bronze HSA - 64004DE0090001 Health Insurance Plan
Celtic Insurance Company health insurance plan with the Plan ID 64004DE0090001. The plan is called Premier Bronze HSA.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 62.87% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 37.13% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 64004DE0090001 | ||||||||||||||||||
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| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Delaware | ||||||||||||||||||
| Health Insurance Issuer | Celtic Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 64004DE0090001-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 17 Jun 2025 12:51 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 64004DE0090001-00 Standard On Exchange Plan - 64004DE0090001-01 |
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| Last Plan Update Date | Wed, 14 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 17 Jun 2025 12:51 GMT |
Premier Bronze HSA Health Insurance Plan Variant 64004DE0090001-00 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 |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Diabetes, Heart Disease, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | DEF001 |
| Formulary URL | URL |
| HIOS Product ID | 64004DE009 |
| Import Date | 2024-08-14 20:01:41 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 62.87% |
| Issuer ID | 64004 |
| Issuer Marketplace Marketing Name | Ambetter Health of Delaware |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | DEN001 |
| 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) | 64004DE0090001-00 |
| Plan Marketing Name | Premier Bronze HSA |
| Plan Type | EPO |
| Plan Variant Marketing Name | Premier Bronze HSA |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,900 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $5,200 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $10 |
| SBC Scenario, Having Diabetes, Copayment | $200 |
| SBC Scenario, Having Diabetes, Deductible | $5,200 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| 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 | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | DES001 |
| Source Name | SERFF |
| Plan ID | 64004DE0090001 |
| State Code | DE |
| 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 | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $10400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,200 |
| 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 | $16100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8050 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,050 |
| 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 Premier Bronze HSA Health Insurance Plan, 64004DE0090001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Premier Bronze HSA, 64004DE0090001 Health Insurance Plan, 64004DE0090001
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Does Premier Bronze HSA Health Insurance Plan, 64004DE0090001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (64004DE0090001) Health Insurance Plan, Variant (64004DE0090001-00) offer Disease Management Programs?
Does (64004DE0090001) Health Insurance Plan, Variant (64004DE0090001-00) have Out Of Country Coverage?
Does (64004DE0090001) Health Insurance Plan, Variant (64004DE0090001-00) have Out of Service Area Coverage?
Does (64004DE0090001) Health Insurance Plan, Variant (64004DE0090001-00) offer Disease Management Programs?
Does Premier Bronze HSA Health Insurance Plan, Variant (64004DE0090001-00) offer Disease Management Programs for Asthma?
Does Premier Bronze HSA Health Insurance Plan, Variant (64004DE0090001-00) offer Disease Management Programs for Heart disease?
Does Premier Bronze HSA Health Insurance Plan, Variant (64004DE0090001-00) offer Disease Management Programs for Diabetes?
Does Premier Bronze HSA Health Insurance Plan, Variant (64004DE0090001-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 17 Jun 2025 12:51 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