Ambetter Balanced Care 12 - 26289NE0020009 Health Insurance Plan

Nebraska Total Care, Inc. health insurance plan with the Plan ID 26289NE0020009. The plan is called Ambetter Balanced Care 12.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 94.02% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 5.98% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.02% (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 5.98% 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 26289NE0020009
Health Insurance Plan Year 2022
State Nebraska
Health Insurance Issuer Nebraska Total Care, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 26289NE0020009-06
Provider Network(s) ['NEN001']
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 Nebraska 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 - 26289NE0020009-00

Standard On Exchange Plan - 26289NE0020009-01

Open to Indians below 300% FPL - 26289NE0020009-02

Open to Indians above 300% FPL - 26289NE0020009-03

73% AV Silver Plan - 26289NE0020009-04

87% AV Silver Plan - 26289NE0020009-05

94% AV Silver Plan - 26289NE0020009-06

Last Plan Update Date Thu, 19 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Ambetter Balanced Care 12 Health Insurance Plan Variant 26289NE0020009-06 Attributes

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
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 $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

Copay & Coinsurance of Ambetter Balanced Care 12 Health Insurance Plan, 26289NE0020009

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

Frequently Asked Questions(FAQ) about Ambetter Balanced Care 12, 26289NE0020009 Health Insurance Plan, 26289NE0020009

  • Does Ambetter Balanced Care 12 Health Insurance Plan, 26289NE0020009 support Mail Ordering?

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

  • 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: 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