Standard Gold + Vision + Adult Dental - 27833IL0150074 Health Insurance Plan

Celtic Insurance Company health insurance plan with the Plan ID 27833IL0150074. The plan is called Standard Gold + Vision + Adult Dental.

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 27833IL0150074
Health Insurance Plan Year 2024
State Illinois
Health Insurance Issuer Celtic Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 27833IL0150074-02
Provider Network(s) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT).

Providers Illinois 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 - 27833IL0150074-00

Standard On Exchange Plan - 27833IL0150074-01

Open to Indians below 300% FPL - 27833IL0150074-02

Open to Indians above 300% FPL - 27833IL0150074-03

Last Plan Update Date Mon, 18 Dec 2023 00:00 GMT
Last Import Date Tue, 22 Oct 2024 06:47 GMT

Benefits of Standard Gold + Vision + Adult Dental Health Insurance Plan, 27833IL0150074-02

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

$0.00, 0.00%

100.00%
Accidental Dental
YES

$0.00, 0.00%

100.00%
Acupuncture
NO
Allergy Testing
YES

$0.00, 0.00%

100.00%
Autism Spectrum Disorders
YES

$0.00, 0.00%

100.00%
Bariatric Surgery
YES

$0.00, 0.00%

100.00%
Basic Dental Care - Adult

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

YES

50.00%

100.00%
Basic Dental Care - Child
NO
Bones/Joints
YES

$0.00, 0.00%

100.00%
Breast Implant Removal
YES

$0.00, 0.00%

100.00%
Cardiac Rehabilitation
YES

$0.00, 0.00%

100.00%
Chemotherapy
YES

$0.00, 0.00%

100.00%
Chiropractic Care

Limit: 25.0 Visit(s) per Year

YES

$0.00, 0.00%

100.00%
Cosmetic Surgery

Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered.

YES

$0.00, 0.00%

100.00%
Delivery and All Inpatient Services for Maternity Care
YES

$0.00, 0.00%

100.00%
Dental Anesthesia
YES

$0.00, 0.00%

100.00%
Dental Check-Up for Children
NO
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, 0.00%
Emergency Transportation/Ambulance

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

YES

$0.00, 0.00%

$0.00, 0.00%
Eye Glasses for Adults
NO
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

$0.00, 0.00%

100.00%
Gender Affirming Care
YES

$0.00, 0.00%

100.00%
Generic Drugs

Cost sharing shown applies to Tier 2-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 3-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

$0.00, 0.00%

100.00%
Habilitation Services
YES

$0.00, 0.00%

100.00%
Hearing Aids

Limit: 2.0 Item(s) per 2 Years

Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit.

YES

$0.00, 0.00%

100.00%
Home Health Care Services
YES

$0.00, 0.00%

100.00%
Hospice Services

Respite Care is covered as part of hospice services only.

YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Infertility Treatment
YES

$0.00, 0.00%

100.00%
Infusion Therapy
YES

$0.00, 0.00%

100.00%
Inherited Metabolic Disorder - PKU
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

Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit.

NO
Major Dental Care - Adult

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

YES

50.00%

100.00%
Major Dental Care - Child
NO
Mental/Behavioral Health Emergency Room
YES

$0.00, 0.00%

$0.00, 0.00%
Mental/Behavioral Health Emergency Transportation/Ambulance

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

YES

$0.00, 0.00%

$0.00, 0.00%
Mental/Behavioral Health ER Physician Fee
YES

$0.00, 0.00%

$0.00, 0.00%
Mental/Behavioral Health Inpatient Services

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

YES

$0.00, 0.00%

100.00%
Mental/Behavioral Health Outpatient Other Services
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Mental/Behavioral Health Urgent Care
YES

$0.00, 0.00%

100.00%
Multiple Sclerosis
YES

$0.00, 0.00%

100.00%
Naprapathic Service

Limit: 15.0 Visit(s) per Year

YES

$0.00, 0.00%

100.00%
Non-Preferred Brand Drugs
YES

$0.00, 0.00%

100.00%
Nutritional Counseling
YES

$0.00, 0.00%

100.00%
Organ Transplants
YES

$0.00, 0.00%

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
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
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%
Prescription Drugs Other
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

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

YES

$0.00, 0.00%

100.00%
Private-Duty Nursing

Available on an outpatient basis only (inpatient excluded)

YES

$0.00, 0.00%

100.00%
Prosthetic Devices
YES

$0.00, 0.00%

100.00%
Radiation
YES

$0.00, 0.00%

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.

YES

$0.00, 0.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

$0.00, 0.00%

100.00%
Rehabilitative Speech Therapy
YES

$0.00, 0.00%

100.00%
Routine Dental Services (Adult)

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

YES

$0.00, 0.00%

100.00%
Routine Eye Exam (Adult)

Limit: 1.0 Exam(s) per Year

Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eye glasses.

YES

$0.00, 0.00%

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

$0.00, 0.00%

100.00%
Routine Foot Care
YES

$0.00, 0.00%

100.00%
Skilled Nursing Facility
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

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

YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Substance Use Disorder Emergency Room
YES

$0.00, 0.00%

$0.00, 0.00%
Substance Use Disorder Emergency Transportation/Ambulance

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

YES

$0.00, 0.00%

$0.00, 0.00%
Substance Use Disorder ER Physician Fee
YES

$0.00, 0.00%

$0.00, 0.00%
Substance Use Disorder Outpatient Other Services
YES

$0.00, 0.00%

100.00%
Substance Use Disorder Urgent Care
YES

$0.00, 0.00%

100.00%
Transplant

Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per 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

Covered in accordance with ACA guidelines.

YES

$0.00, 0.00%

100.00%
X-rays and Diagnostic Imaging
YES

$0.00, 0.00%

100.00%

Standard Gold + Vision + Adult Dental Health Insurance Plan Variant 27833IL0150074-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1.0
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 Zero Cost Sharing Plan Variation
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 0.9675
First Tier Utilization 100%
Formulary ID ILF013
Formulary URL URL
HIOS Product ID 27833IL015
Import Date 2023-12-18 20:02:01
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 Yes
Is a Referral Required for Specialist? No
Issuer ID 27833
Issuer Marketplace Marketing Name Ambetter of Illinois
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 ILN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 2024-01-01
Plan ID (Standard Component ID with Variant) 27833IL0150074-02
Plan Marketing Name Standard Gold + Vision + Adult Dental
Plan Type HMO
Plan Variant Marketing Name Standard Gold + Vision + Adult Dental
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 ILS001
Source Name SERFF
Plan ID 27833IL0150074
State Code IL
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 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 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 $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 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 No

Copay & Coinsurance of Standard Gold + Vision + Adult Dental Health Insurance Plan, 27833IL0150074

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

Frequently Asked Questions(FAQ) about Standard Gold + Vision + Adult Dental, 27833IL0150074 Health Insurance Plan, 27833IL0150074

  • Does Standard Gold + Vision + Adult Dental Health Insurance Plan, 27833IL0150074 support Mail Ordering?

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

  • Does (27833IL0150074) Health Insurance Plan, Variant (27833IL0150074-02) offer Disease Management Programs?

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

    Does (27833IL0150074) Health Insurance Plan, Variant (27833IL0150074-02) have Out Of Country Coverage?

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

    Does (27833IL0150074) Health Insurance Plan, Variant (27833IL0150074-02) 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 (27833IL0150074) Health Insurance Plan, Variant (27833IL0150074-02) offer Disease Management Programs?

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

    Does Standard Gold + Vision + Adult Dental Health Insurance Plan, Variant (27833IL0150074-02) offer Disease Management Programs for Asthma?

    Yes, the Standard Gold + Vision + Adult Dental Health Insurance Plan Variant 27833IL0150074-02 offers Disease Management Program for Asthma.

    Does Standard Gold + Vision + Adult Dental Health Insurance Plan, Variant (27833IL0150074-02) offer Disease Management Programs for Heart disease?

    Yes, the Standard Gold + Vision + Adult Dental Health Insurance Plan Variant 27833IL0150074-02 offers Disease Management Program for Heart disease.

    Does Standard Gold + Vision + Adult Dental Health Insurance Plan, Variant (27833IL0150074-02) offer Disease Management Programs for Diabetes?

    Yes, the Standard Gold + Vision + Adult Dental Health Insurance Plan Variant 27833IL0150074-02 offers Disease Management Program for Diabetes.

    Does Standard Gold + Vision + Adult Dental Health Insurance Plan, Variant (27833IL0150074-02) offer Disease Management Programs for Pregnancy?

    Yes, the Standard Gold + Vision + Adult Dental Health Insurance Plan Variant 27833IL0150074-02 offers Disease Management Program for Pregnancy.

 

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