| Field | Data |
|---|---|
| Health Insurance Plan ID | 26289NE0020009 |
| Health Insurance Plan Year | 2022 |
| State | Nebraska |
| Health Insurance Issuer | Nebraska Total Care, Inc. |
| Plan Marketing Materials URL | Marketing URL |
| Last Plan Update Date | Mon, 16 Aug 2021 00:00 GMT |
| Last Import Date | Tue, 21 Mar 2023 13:10 GMT |
| Health Insurance Plan Variant | 26289NE0020009-06 |
| Available Variants of the Health Plan | |
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.940248214 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2022 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | 94% AV Level Silver Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | NEF006 |
| Formulary URL | URL |
| HIOS Product ID | 26289NE002 |
| Import Date | 8/19/2021 21:26 |
| 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 Actuarial Value | 94.02% |
| Issuer ID | 26289 |
| Issuer Marketplace Marketing Name | Ambetter from Nebraska Total Care |
| 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 | NEN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan ID (Standard Component ID with Variant) | 26289NE0020009-06 |
| Plan Marketing Name | Ambetter Balanced Care 12 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Ambetter Balanced Care 12 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,400 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $200 |
| SBC Scenario, Having Diabetes, Copayment | $400 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $30 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NES001 |
| Source Name | SERFF |
| Plan ID | 26289NE0020009 |
| State Code | NE |
| 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 | 25.00% |
| 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 |
| TEHBDedOutOfNetFamilyPerGroup | per group not applicable |
| TEHBDedOutOfNetFamilyPerPerson | 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 | $2800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $1400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $1,400 |
| 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 |
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|---|---|---|---|---|---|
| Generic | 1 month in retail | $0 | 0% | YES | ||
| Generic | 3 month in mail | $0 | 0% | YES | ||
| Non preferred brand | 1 month in retail | $0 | No charge | 50.0% | After deductible | YES |
| Non preferred brand | 3 month in mail | $0 | No charge | 42.0% | After deductible | YES |
| Preferred brand | 1 month in retail | $0 | 0% | YES | ||
| Preferred brand | 3 month in mail | $0 | 0% | YES | ||
| Preferredgeneric | 1 month in retail | $0 | 0% | YES | ||
| Preferredgeneric | 3 month in mail | $0 | 0% | YES | ||
| Specialty | 1 month in retail | $0 | No charge | 50.0% | After deductible | YES |
| Specialty | 3 month in mail | $0 | No charge | 50.0% | After deductible | YES |
Frequently Asked Questions(FAQ) about Ambetter Balanced Care 12 (2022), 26289NE0020009 Health Insurance Plan, 26289NE0020009
Does Ambetter Balanced Care 12 (2022) Health Insurance Plan, 26289NE0020009 support Mail Ordering?
Yes, Ambetter Balanced Care 12 (2022) Health Insurance
Plan, 26289NE0020009 supports mail ordering for the next drug tiers: Generic, Non preferred brand, Preferred brand, Preferredgeneric, Specialty
What are the Generic Medications coinsurance & copay options with Ambetter Balanced Care 12 (2022) (26289NE0020009) Health Insurance Plan?
For generic drug tier, generic drug tier, preferredgeneric drug tier, preferredgeneric drug tier
What are the copay and coinsurance options for Brand Drugs with Ambetter Balanced Care 12 (2022) Health Insurance Plan (26289NE0020009)?
For non preferred brand drug tier copay (No charge) is $0.0 and coinsurance (After deductible) is 50.0%, non preferred brand drug tier copay (No charge) is $0.0 and coinsurance (After deductible) is 42.0%, preferred brand drug tier, preferred brand drug tier
What are the copay and coinsurance options for Brand Drugs with Ambetter Balanced Care 12 (2022) Health Insurance Plan (26289NE0020009)?
, non preferred brand drug tier copay (No charge) is $0.0 and coinsurance (After deductible) is 50.0%, non preferred brand drug tier copay (No charge) is $0.0 and coinsurance (After deductible) is 42.0%, preferred brand drug tier, preferred brand drug tier
Does (26289NE0020009) Health Insurance Plan, Variant (26289NE0020009-06) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy
Does (26289NE0020009) Health Insurance Plan, Variant (26289NE0020009-06) have Out Of Country Coverage?
No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).
Does (26289NE0020009) Health Insurance Plan, Variant (26289NE0020009-06) 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 (26289NE0020009) Health Insurance Plan, Variant (26289NE0020009-06) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy
Does Ambetter Balanced Care 12 Health Insurance Plan, Variant (26289NE0020009-06) offer Disease Management Programs for Asthma?
Yes, the Ambetter Balanced Care 12 Health Insurance Plan Variant 26289NE0020009-06 offers Disease Management Program for Asthma.
Does Ambetter Balanced Care 12 Health Insurance Plan, Variant (26289NE0020009-06) offer Disease Management Programs for Heart disease?
Yes, the Ambetter Balanced Care 12 Health Insurance Plan Variant 26289NE0020009-06 offers Disease Management Program for Heart disease.
Does Ambetter Balanced Care 12 Health Insurance Plan, Variant (26289NE0020009-06) offer Disease Management Programs for Diabetes?
Yes, the Ambetter Balanced Care 12 Health Insurance Plan Variant 26289NE0020009-06 offers Disease Management Program for Diabetes.
Does Ambetter Balanced Care 12 Health Insurance Plan, Variant (26289NE0020009-06) offer Disease Management Programs for Pregnancy?
Yes, the Ambetter Balanced Care 12 Health Insurance Plan Variant 26289NE0020009-06 offers Disease Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Tue, 21 Mar 2023 13:10 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