Standard Bronze 7500 - 67243LA0090047 Health Insurance Plan

Vantage Health Plan, Inc. health insurance plan with the Plan ID 67243LA0090047. The plan is called Standard Bronze 7500.

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 67243LA0090047
Health Insurance Plan Year 2023
State Louisiana
Health Insurance Issuer Vantage Health Plan, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 67243LA0090047-02
Provider Network(s) ['LAN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Louisiana 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 - 67243LA0090047-00

Standard On Exchange Plan - 67243LA0090047-01

Open to Indians below 300% FPL - 67243LA0090047-02

Open to Indians above 300% FPL - 67243LA0090047-03

Last Plan Update Date Thu, 18 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Standard Bronze 7500 Health Insurance Plan, 67243LA0090047-02

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

$0.00, 0.00%

$0.00, 0.00%
Acupuncture
NO
Allergy Testing
YES

$0.00, 0.00%

$0.00, 0.00%
Bariatric Surgery
NO
Basic Dental Care - Adult

An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care.

YES

$0.00, 0.00%

$0.00, 0.00%
Basic Dental Care - Child
YES

$0.00, 0.00%

$0.00, 0.00%
Chemotherapy
YES

$0.00, 0.00%

$0.00, 0.00%
Chiropractic Care
YES

$0.00, 0.00%

$0.00, 0.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Minimum stay of 48 hours

YES

$0.00, 0.00%

$0.00, 0.00%
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Year

YES

$0.00, 0.00%

$0.00, 0.00%
Diabetes Education
YES

$0.00, 0.00%

$0.00, 0.00%
Dialysis
YES

$0.00, 0.00%

$0.00, 0.00%
Durable Medical Equipment

Various limitations apply as stated in the Benchmark plan.

YES

$0.00, 0.00%

$0.00, 0.00%
Emergency Room Services

The ER Copay is waived if the visit results in an inpatient admission.

YES

$0.00, 0.00%

$0.00, 0.00%
Emergency Transportation/Ambulance

Air ambulance services are covered in only specified situations.

YES

$0.00, 0.00%

$0.00, 0.00%
Eye Glasses for Children

Limit: 1.0 Visit(s) per Year

YES

$0.00, 0.00%

$0.00, 0.00%
Gender Affirming Care
NO
Generic Drugs

Quantity limits, authorizations and step therapy limits may apply.

YES

$0.00, 0.00%

100.00%
Habilitation Services

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

YES

$0.00, 0.00%

$0.00, 0.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

YES

$0.00, 0.00%

$0.00, 0.00%
Home Health Care Services

Home Health Care services provided to a Member in lieu of an Inpatient Hospital Admission are covered; must obtain authorization.

YES

$0.00, 0.00%

$0.00, 0.00%
Hospice Services
YES

$0.00, 0.00%

$0.00, 0.00%
Imaging (CT/PET Scans, MRIs)
YES

$0.00, 0.00%

$0.00, 0.00%
Infertility Treatment
NO
Infusion Therapy
YES

$0.00, 0.00%

$0.00, 0.00%
Inpatient Hospital Services (e.g., Hospital Stay)

Copays, if applicable, are per day for first three days only.

YES

$0.00, 0.00%

$0.00, 0.00%
Inpatient Physician and Surgical Services
YES

$0.00, 0.00%

$0.00, 0.00%
Laboratory Outpatient and Professional Services

Lab services in the Emergency Room are subject to the deductible, if applicable.

YES

$0.00, 0.00%

$0.00, 0.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult

An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care.

YES

$0.00, 0.00%

$0.00, 0.00%
Major Dental Care - Child
YES

$0.00, 0.00%

$0.00, 0.00%
Mental/Behavioral Health Inpatient Services

Inpatient treatment for mental/behavioral health disorders must be Authorized as provided in the Care Management Article of this Benefit Plan.

YES

$0.00, 0.00%

$0.00, 0.00%
Mental/Behavioral Health Outpatient Services
YES

$0.00, 0.00%

$0.00, 0.00%
Non-Preferred Brand Drugs

Quantity limits, authorizations and step therapy limits may apply.

YES

$0.00

100.00%
Nutritional Counseling

Limit: 4.0 Visit(s) per Benefit Period

Coverage only for diabetes education.

YES

$0.00, 0.00%

$0.00, 0.00%
Orthodontia - Adult
NO
Orthodontia - Child

Medically Necessary orthodontia only.

YES

$0.00, 0.00%

$0.00, 0.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)

Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization.

YES

$0.00, 0.00%

$0.00, 0.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

$0.00, 0.00%

$0.00, 0.00%
Outpatient Rehabilitation Services
YES

$0.00, 0.00%

$0.00, 0.00%
Outpatient Surgery Physician/Surgical Services
YES

$0.00, 0.00%

$0.00, 0.00%
Preferred Brand Drugs

Quantity limits, authorizations and step therapy limits may apply.

YES

$0.00

100.00%
Prenatal and Postnatal Care
YES

$0.00, 0.00%

$0.00, 0.00%
Preventive Care/Screening/Immunization

Quantitative limit units apply, see Benchmark plan.

YES

$0.00, 0.00%

$0.00, 0.00%
Primary Care Visit to Treat an Injury or Illness

Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization.

YES

$0.00, 0.00%

$0.00, 0.00%
Private-Duty Nursing

Limit: 150.0 Hours per Benefit Period

Inpatient private-duty nursing services are not covered.

YES

$0.00, 0.00%

100.00%
Prosthetic Devices

Various limitations apply as stated in the Benchmark plan.

YES

$0.00, 0.00%

$0.00, 0.00%
Radiation
YES

$0.00, 0.00%

$0.00, 0.00%
Reconstructive Surgery

Plan only outlines benefits for breast reconstruction. Must be medically necessary and related to mastectomy.

YES

$0.00, 0.00%

$0.00, 0.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Rehabilitative Occupational and Physical Therapies are included in the Outpatient Rehabilitation Services benefit listed in Line 91 above.

YES

$0.00, 0.00%

$0.00, 0.00%
Rehabilitative Speech Therapy

Rehabilitative Speech Therapy is included in the Outpatient Rehabilitation Services benefit listed in Line 91 above.

YES

$0.00, 0.00%

$0.00, 0.00%
Routine Dental Services (Adult)

Limit: 2.0 Visit(s) per Year

Covers exam and cleaning

YES

$0.00, 0.00%

$0.00, 0.00%
Routine Eye Exam (Adult)

Limit: 1.0 Visit(s) per Year

An added benefit

YES

$0.00, 0.00%

$0.00, 0.00%
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

$0.00, 0.00%

$0.00, 0.00%
Routine Foot Care
YES

$0.00, 0.00%

$0.00, 0.00%
Skilled Nursing Facility

Three-day prior inpatient stay

YES

$0.00, 0.00%

$0.00, 0.00%
Specialist Visit

Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization.

YES

$0.00, 0.00%

$0.00, 0.00%
Specialty Drugs

Specialty drugs may be limited to a thirty (30) day supply. Quantity limits, authorizations and step therapy limits may apply.

YES

$0.00

100.00%
Substance Abuse Disorder Inpatient Services

Inpatient treatment for substance abuse must be Authorized as provided in the Care Management Article of this Benefit Plan, when coverage for alcohol and/or drug abuse is provided.

YES

$0.00, 0.00%

$0.00, 0.00%
Substance Abuse Disorder Outpatient Services

Covered Services will be only those, which are for treatment for abuse of alcohol, drugs or other chemicals, and the resultant physiological and/or psychological dependency, which develops with continued use.

YES

$0.00, 0.00%

$0.00, 0.00%
Transplant

Exclusions: Non-EHB and out-of-network transplant services

YES

$0.00, 0.00%

$0.00, 0.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$0.00, 0.00%

$0.00, 0.00%
Weight Loss Programs

Exclusions: Non-Vantage Weight Loss programs are excluded.

Vantage Weight Loss programs are covered as part of the Vantage Wellness Program.

YES

$0.00, 0.00%

100.00%
Well Baby Visits and Care
YES

$0.00, 0.00%

$0.00, 0.00%
X-rays and Diagnostic Imaging
YES

$0.00, 0.00%

$0.00, 0.00%

Standard Bronze 7500 Zero Health Insurance Plan Variant 67243LA0090047-02 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 Design 2
Disease Management Programs Offered Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Weight Loss Programs
EHB Percent of Total Premium 0.96965
First Tier Utilization 100%
Formulary ID LAF001
Formulary URL URL
HIOS Product ID 67243LA009
Import Date 8/18/2022 1:00
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 67243
Issuer Marketplace Marketing Name Vantage Health Plan
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 LAN001
Out of Country Coverage Yes
Out of Country Coverage Description Limited to Emergency Services only. Covered as in-network.
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Out-of-Network Deductible and Co-insurance
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 67243LA0090047-02
Plan Marketing Name Standard Bronze 7500
Plan Type POS
Plan Variant Marketing Name Standard Bronze 7500 Zero
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 LAS001
Source Name HIOS
Plan ID 67243LA0090047
State Code LA
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 Standard Bronze 7500 Health Insurance Plan, 67243LA0090047

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

Frequently Asked Questions(FAQ) about Standard Bronze 7500, 67243LA0090047 Health Insurance Plan, 67243LA0090047

  • Does Standard Bronze 7500 Health Insurance Plan, 67243LA0090047 support Mail Ordering?

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

  • Does (67243LA0090047) Health Insurance Plan, Variant (67243LA0090047-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Weight Loss Programs

    Does (67243LA0090047) Health Insurance Plan, Variant (67243LA0090047-02) have Out Of Country Coverage?

    Yes. Details: Limited to Emergency Services only. Covered as in-network.

    Does (67243LA0090047) Health Insurance Plan, Variant (67243LA0090047-02) have Out of Service Area Coverage?

    Yes. Details: Out-of-Network Deductible and Co-insurance

    Does (67243LA0090047) Health Insurance Plan, Variant (67243LA0090047-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Weight Loss Programs

    Does Standard Bronze 7500 Zero Health Insurance Plan, Variant (67243LA0090047-02) offer Disease Management Programs for Heart disease?

    Yes, the Standard Bronze 7500 Zero Health Insurance Plan Variant 67243LA0090047-02 offers Disease Management Program for Heart disease.

    Does Standard Bronze 7500 Zero Health Insurance Plan, Variant (67243LA0090047-02) offer Disease Management Programs for Depression?

    Yes, the Standard Bronze 7500 Zero Health Insurance Plan Variant 67243LA0090047-02 offers Disease Management Program for Depression.

    Does Standard Bronze 7500 Zero Health Insurance Plan, Variant (67243LA0090047-02) offer Disease Management Programs for Diabetes?

    Yes, the Standard Bronze 7500 Zero Health Insurance Plan Variant 67243LA0090047-02 offers Disease Management Program for Diabetes.

    Does Standard Bronze 7500 Zero Health Insurance Plan, Variant (67243LA0090047-02) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Standard Bronze 7500 Zero Health Insurance Plan Variant 67243LA0090047-02 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Standard Bronze 7500 Zero Health Insurance Plan, Variant (67243LA0090047-02) offer Disease Management Programs for Weight loss programs?

    Yes, the Standard Bronze 7500 Zero Health Insurance Plan Variant 67243LA0090047-02 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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