Summa Insurance Company, Inc. health insurance plan with the Plan ID 52664OH1530028. The plan is called SummaCare Silver 3500 with SCConnect Network and 3 Free PCP Visits.
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 | 52664OH1530028 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Ohio | ||||||||||||||||||
Health Insurance Issuer | Summa Insurance Company, Inc. | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 52664OH1530028-02 | ||||||||||||||||||
Provider Network(s) | ['OHN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 14 May 2024 06:16 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 52664OH1530028-00 Standard On Exchange Plan - 52664OH1530028-01 Open to Indians below 300% FPL - 52664OH1530028-02 Open to Indians above 300% FPL - 52664OH1530028-03 73% AV Silver Plan - 52664OH1530028-04 |
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Last Plan Update Date | Thu, 15 Sep 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 14 May 2024 06:16 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
Limit: 3000.0 Dollars per Episode Exclusions: Damage to teeth due to chewing or biting is not deemed an accidental injury and is not covered. Quantitative Limit represents established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply. Coverage for dental services resulting from an accidental injury when treatment is performed within 12 months after the injury. The benefit limit will not apply to outpatient facility charges, anesthesia billed by a provider other than the physician performing the service, or to covered services required by law; coverage includes oral examinations, x-rays, tests and laboratory examinations, restorations, prosthetic services, oral surgery, mandibular/maxillary reconstruction, anesthesia and include facility charges for outpatient services for the removal of teeth or for other dental processes if the patient?s medical condition or the dental procedure requires a hospital setting to ensure the safety of the patient. |
YES | $0.00, 0.00% |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | $0.00, 0.00% |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
Exclusions: Adult dental treatment, regardless of origin or cause, is excluded except as specified in the base-benchmark plan when related to accidental injury (limits apply), or for certain services related to transplant preparation, initiation of immunosuppresives, or direct treatment of acute traumatic injury, cancer or cleft palate. Excluded dental treatment includes but is not limited to: Preventive care, diagnosis, treatment of or related to the teeth, jawbones (except that TMJ is a Covered Service) or gums. See Accidental Dental benefit for additional information. |
NO | ||
Basic Dental Care - Child
Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan. |
NO | ||
Chemotherapy
|
YES | $0.00, 0.00% |
100.00% |
Chiropractic Care
Limit: 12.0 Visit(s) per Benefit Period Exclusions: Manipulation therapy services rendered in the home as part of Home Care Services. Benefit limit applies for Osteopathic/Chiropractic Manipulation Therapy. |
YES | $0.00, 0.00% |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
Exclusions: Any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple). Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Prenatal Care. |
YES | $0.00, 0.00% |
100.00% |
Dental Check-Up for Children
Limit: 1.0 Exam(s) per 6 Months Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan. |
NO | ||
Diabetes Education
Diabetes Self-Management Training for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition. |
YES | $0.00, 0.00% |
100.00% |
Dialysis
Benefits include supportive use of an artificial kidney machine. |
YES | $0.00, 0.00% |
100.00% |
Durable Medical Equipment
Exclusions: Items for personal hygiene, environmental control or convenience; exercise equipment; repair and replacement due to misuse, malicious breakage or gross neglect, loss or theft; medical and surgical supplies (usually stocked in the home for general use like- band aids, thermometers, and petroleum jelly); arch supports; doughnut cushions; vitamins; medi-jectors; air conditioners; hot packs; ice bags/ cold pack pump; raised toilet seats; rental of equipment where facility is expected to provide such equipment; trans lift chairs; treadmill exerciser; tub chair; dentures, dental appliances; non-rigid appliances; artificial heart implants; wigs (except following cancer treatment); penile prosthesis in men suffering impotency; orthopedic shoes (except therapeutic shoes for diabetics); foot support devices and corrective shoes, unless they are an integral part of a leg brace; standard elastic stockings and other supplies not specially made and fitted (except as specified under medical supplies); garter belts or similar devices. Covered services include durable medical equipment, medical devices and supplies, prosthetics and appliances, including cochlear implants and eyeglasses/contact lenses (for cataract surgery or injury), and medical/surgical supplies and equipment that serve only a medical purpose for the management of disease. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period; (as required by the Women?s Health and Cancer Rights Act); Left Ventricular Artificial Devices (LVAD) covered only as bridge to heart transplant. |
YES | $0.00, 0.00% |
100.00% |
Emergency Room Services
Exclusions: For care received in an emergency room, which is not, Emergency Care, including, but not limited to suture removal in an emergency room. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Emergency Transportation/Ambulance
Exclusions: Non Covered Services for Ambulance include but are not limited to, trips to: a Physician's office or clinic; a morgue or funeral home; ambulance usage when another type of transportation can be used without endangering the member's health or any ambulance usage for the convenience of the member, family, or physician; transport by ambulette. Out-of-network ambulance services are excluded except in an emergency or with prior authorization. Ambulance Services are transportation by a vehicle (including ground, water, fixed wing and rotary wing air transportation) designed, equipped and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals: from home, scene of accident or medical emergency to a hospital; between hospitals; between a hospital and skilled nursing facility; or from a hospital or skilled nursing facility to home; ambulance trips must be made to the closest facility that can give covered services appropriate for the member's condition. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits. |
YES | No Charge |
100.00% |
Gender Affirming Care
Exclusions: Procedures performed for the sole purpose of improving or altering appearance or self-esteem related to one's appearance are considered cosmetic in nature, not medically necessary and not covered services. Transexual surgery and related services including pre and post-surgery diagnostics, treatments, and drug therapy must be prior authorized and will be covered based upon medical necessity. Cost shares are based on where the transsexual surgery and related services are provided. |
YES | 0.00% |
100.00% |
Generic Drugs
Exclusions: Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications. Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits. |
YES | $0.00, 0.00% |
100.00% |
Habilitation Services
Limits may apply to some services; includes benefits for health care services and devices that help a person keep, learn or improve skills and functioning for daily living, including treatment of Autism Spectrum Disorders to children (0 - 21), which at a minimum shall include: (1) Out-Patient Physical Rehabilitation Services including (a) Speech and Language therapy and/or Occupational therapy, 20 visits per year of each service; and (b) Clinical Therapeutic Intervention, which include but are not limited to Applied Behavioral Analysis, 20 hours per week; and (2) Mental/Behavioral Health Outpatient Services to provide consultation, assessment, development and oversight of treatment plans. |
YES | $0.00, 0.00% |
100.00% |
Hearing Aids
|
NO | ||
Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period Exclusions: Food, housing, homemaker services and home delivered meals; Home or Outpatient hemodialysis services (these are covered under Therapy Services); Physician charges; Helpful environmental materials (hand rails, ramps, telephones, air conditioners, and similar services, appliances and devices); Services provided by registered nurses and other health workers who are not acting as employees or under approved arrangements with a contracting Home Health Care Provider; Services provided by a member of the patient's immediate family; Services provided by volunteer ambulance associations for which patient is not obligated to pay; visiting teachers, vocational guidance and other counselors, and services related to outside occupational and social activities; Manipulation Therapy services rendered in the home. When therapy services are provided in the home (including physical, speech, and occupational therapy) as part of home health care services, they are not subject to separate visit limits for therapy services. The 100 visit/year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting. |
YES | $0.00, 0.00% |
100.00% |
Hospice Services
To be eligible for Hospice benefits, the patient must have a life expectancy of six months or less, as confirmed by the attending Physician. |
YES | $0.00, 0.00% |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | $0.00, 0.00% |
100.00% |
Infertility Treatment
Exclusions: Infertility treatment is excluded except as required under state law for HMO plans Infertility and voluntary family planning services are required benefits under state law for HMO plans only per ORC section 1751.01 (A)(1)(h), and must be provided in accordance with Ohio Department of Insurance Bulletin No. 2009-07. |
YES | $0.00, 0.00% |
100.00% |
Infusion Therapy
Home IV therapy includes but is not limited to: injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy. |
YES | $0.00, 0.00% |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: Surgical treatment of dental conditions, reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dysfunction; surgeries or services for sexual transformation; surgical treatment of flat feet, subluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremity; treatment of telangiectatic dermal veins; cosmetic surgery; bariatric surgery. There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services; and ancillary (related) services. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services. |
YES | $0.00, 0.00% |
100.00% |
Inpatient Physician and Surgical Services
Exclusions: Surgical treatment of dental conditions, reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dysfunction; surgeries or services for sexual transformation; surgical treatment of flat feet, subluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremity; treatment of telangiectatic dermal veins; cosmetic surgery; bariatric surgery. There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient medical care visits limited to one visit per day by any one physician. |
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
Exclusions: Adult dental treatment, regardless of origin or cause, is excluded except as specified in the base-benchmark plan when related to accidental injury (limits apply), or for certain services related to transplant preparation, initiation of immunosuppresives, or direct treatment of acute traumatic injury, cancer or cleft palate. Excluded dental treatment includes but is not limited to: Preventive care, diagnosis, treatment of or related to the teeth, jawbones (except that TMJ is a Covered Service) or gums. See Accidental Dental benefit for additional information. |
NO | ||
Major Dental Care - Child
Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan. |
NO | ||
Mental/Behavioral Health Inpatient Services
Exclusions: Custodial or domiciliary Care. Room and board charges unless the treatment provided meets medical necessity criteria for Inpatient admission for patient's condition. Supervised living or halfway houses, services or care provided or billed by a hotel, health resort, convalescent/rest/nursing home, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps. Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $0.00, 0.00% |
100.00% |
Mental/Behavioral Health Outpatient Services
Exclusions: Custodial or domiciliary Care. Supervised living or halfway houses, services or care provided or billed by a hotel, health resort, convalescent/rest/nursing home, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps. Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $0.00, 0.00% |
100.00% |
Non-Preferred Brand Drugs
Exclusions: Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits. |
YES | $0.00, 0.00% |
100.00% |
Nutritional Counseling
Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services (includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors). |
YES | $0.00, 0.00% |
100.00% |
Orthodontia - Adult
Exclusions: Adult dental treatment, regardless of origin or cause, is excluded except as specified in the base-benchmark plan when related to accidental injury (limits apply), or for certain services related to transplant preparation, initiation of immunosuppresives, or direct treatment of acute traumatic injury, cancer or cleft palate. Excluded dental treatment includes but is not limited to: Preventive care, diagnosis, treatment of or related to the teeth, jawbones (except that TMJ is a Covered Service) or gums. See Accidental Dental benefit for additional information. |
NO | ||
Orthodontia - Child
Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan. |
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00, 0.00% |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: Surgical treatment of dental conditions, reversal of voluntary sterilzation; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dsfunction; surgeries or services for sexual transformation,; surgical treatment of flat feet, sugbluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremelty; tretment of telangtiectatic dermal veins; cosmetic surgery; bariatric surgery. See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document; benefits for facility charges for Outpatient Services are payable for the removal of teeth or for other dental processes only if the patient?s medical condition or the dental procedure requires a Hospital setting to ensure the safety of the patient |
YES | $0.00, 0.00% |
100.00% |
Outpatient Rehabilitation Services
Limit: 116.0 Visit(s) per Benefit Period Exclusions: Non-Covered Services include: Physical Therapy - maintenance therapy, repetitive exercise, range of motion and passive exercises that are not related to restoration of a specific loss of function; general exercise programs; diathermy, ultrasound and heat treatments for pulmonary conditions; diapulse; work hardening. Occupational Therapy - diversional, recreational, vocational therapies and supplies; general exercises to promote overall fitness and flexibility; therapy to improve motivation; suction therapy for newborns (feeding machines); soft tissue mobilization (visceral manipulation or visceral soft tissue manipulation), augmented soft tissue mobilization, myofascial; adaptions to the home. Cardiac Rehabilitation - home programs, ongoing conditioning and maintenance. Pulmonary Rehabilitation - services provided in the acute inpatient rehabilitation setting Therapy Services rendered in the home as part of Home Care Services will be subject to the Home Care Services visit limits; outpatient rehabilitation services visit limits will not apply. If different types of Therapy Services are performed during one Physician Home Visit, Office Service, or Outpatient Service, then each different type of Therapy Service performed will be considered a separate Therapy Visit. Each Therapy Visit will count against the applicable maximum visits per Benefit Period listed below: Physical, Occupational and Speech Therapy limited to 20 visits each. Cardiac Rehabilitation limited to 36 visits. Pulmonary Rehabilitation limited to 20 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply. Benefit also includes Physical Medicine and Rehabilitation Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services. |
YES | $0.00, 0.00% |
100.00% |
Outpatient Surgery Physician/Surgical Services
Exclusions: Surgical treatment of dental conditions, reversal of voluntary sterilzation; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dsfunction; surgeries or services for sexual transformation,; surgical treatment of flat feet, sugbluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremelty; tretment of telangtiectatic dermal veins; cosmetic surgery; bariatric surgery. See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document. |
YES | $0.00, 0.00% |
100.00% |
Preferred Brand Drugs
Exclusions: Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications. Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits. |
YES | $0.00, 0.00% |
100.00% |
Prenatal and Postnatal Care
Exclusions: Any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple). Includes post-delivery follow-up care performed, by a physician or nurse, within 72 hours of discharge, through home health care visits or, at patient?s discretion, in a medical setting. This coverage includes, but is not limited to parent education; assistance and training in breast or bottle feeding; and routine maternal or neonatal tests and screening (including collection of sample for hereditary and metabolic newborn screening). |
YES | $0.00, 0.00% |
100.00% |
Preventive Care/Screening/Immunization
Services with an 'A' or 'B' rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration including: women?s contraceptives, sterilization procedures, and counseling; breastfeeding support, supplies, and counseling (benefits for breast pumps are limited to one pump per benefit period); and gestational diabetes screening; routine screening mammograms; routine cytologic screening; child health supervision services from birth to age 9. |
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
Limit: 90.0 Visit(s) per Benefit Period Private Duty Nursing Services are Covered Services only when provided through the Home Care Services benefit; Quantitative Limit has been determined as 90 - 110 visits per year and represents the number of visits to meet the established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply. |
YES | $0.00, 0.00% |
100.00% |
Prosthetic Devices
Exclusions: Dentures, replacing teeth or structures directly supporting teeth; Dental appliances; Such non-rigid appliances as elastic stockings, garter belts, arch supports and corsets; Artificial heart implants; Wigs (except following cancer treatment); Penile prosthesis in men suffering impotency resulting from disease or injury. Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that 1) Replace all or part of a missing body part and its adjoining tissues; or 2) Replace all or part of the function of a permanently useless or malfunctioning body part. |
YES | $0.00, 0.00% |
100.00% |
Radiation
|
YES | $0.00, 0.00% |
100.00% |
Reconstructive Surgery
Exclusions: Reconstructive services needed as a result of an earlier treatment are covered only if the first treatment would have been a covered service under the plan; coverage for reconstructive services does not apply to orthognathic surgery. Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy. |
YES | $0.00, 0.00% |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Benefit Period Exclusions: Non-Covered Services include:Physical Therapy - maintenance therapy, repetitive exercise, range of motion and passive exercises that are not relatedto restoration of a specific loss of function; general exercise programs; diathermy, ultrasound and heat treatments for pulmonary conditions; diapulse;work hardening. Occupational Therapy - diversional, recreational, vocational therapies and supplies; general exercisesto promote overall fitness and flexibility; therapy to improve motivation; suction therapy for newborns (feeding machines); soft tissue mobilization (visceral manipulation or visceral soft tissue manipulation), augmented soft tissue mobilization, myofascial; adaptions to the home. Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period. |
YES | $0.00 |
100.00% |
Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period |
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 Exam(s) per Year Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits. |
YES | No Charge |
100.00% |
Routine Foot Care
|
NO | ||
Skilled Nursing Facility
Limit: 90.0 Days per Benefit Period Exclusions: Custodial or domiciliary care. Benefits include Items and services provided as an inpatient in a skilled nursing bed of skilled nursing facility or hospital, including room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies. |
YES | $0.00, 0.00% |
100.00% |
Specialist Visit
|
YES | $0.00, 0.00% |
100.00% |
Specialty Drugs
Exclusions: Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications. Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits. |
YES | $0.00, 0.00% |
100.00% |
Substance Abuse Disorder Inpatient Services
Exclusions: Custodial or domiciliary Care. Room and board charges unless the treatment provided meets medical necessity criteria for Inpatient admission for patient's condition. Supervised living or halfway houses, services or care provided or billed by a hotel, health resort, convalescent/rest/nursing home, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps. Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $0.00, 0.00% |
100.00% |
Substance Abuse Disorder Outpatient Services
Exclusions: Services or care provided or billed by a halfway house, hotel, health resort, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps. Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $0.00, 0.00% |
100.00% |
Transplant
Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined). Transplant benefits apply to any medically necessary human organ and stem cell/bone marrow transplants (except cornea and kidney transplants) and transfusions including necessary acquisition procedures, harvest and storage, necessary preparatory myeloablative therapy, and initial evaluation/testing to determine eligibility as a transplant candidate. |
YES | 0.00% |
100.00% |
Treatment for Temporomandibular Joint Disorders
Benefits provided for temporomandibular (joint connecting the lower jaw to the temporal bone at the side of the head) and craniomandibular (head and neck muscle) disorders. |
YES | $0.00, 0.00% |
100.00% |
Urgent Care Centers or Facilities
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
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% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 1 |
Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
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, Pregnancy, Weight Loss Programs |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 100% |
Formulary ID | OHF002 |
Formulary URL | URL |
HIOS Product ID | 52664OH153 |
Import Date | 9/15/2022 20:01 |
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 | 52664 |
Issuer Marketplace Marketing Name | SummaCare |
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 | OHN001 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Emergency Coverage |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Emergent and Urgent Care Coverage |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan ID (Standard Component ID with Variant) | 52664OH1530028-02 |
Plan Level Exclusions | No |
Plan Marketing Name | SummaCare Silver 3500 with SCConnect Network and 3 Free PCP Visits |
Plan Type | HMO |
Plan Variant Marketing Name | SummaCare Silver 3500-100 with SCConnect Network and 3 Free PCP Visits |
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 | OHS001 |
Source Name | SERFF |
Plan ID | 52664OH1530028 |
State Code | OH |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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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, 14 May 2024 06:16 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