Ambetter Balanced Care 4 + Vision + Adult Dental - 62141AR0100013 Health Insurance Plan

Celtic Insurance Company health insurance plan with the Plan ID 62141AR0100013. The plan is called Ambetter Balanced Care 4 + Vision + Adult Dental.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.94% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.06% 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 70.94% (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 29.06% 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 62141AR0100013
Health Insurance Plan Year 2022
State Arkansas
Health Insurance Issuer Celtic Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 62141AR0100013-00
Provider Network(s) ['ARN001']
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 Arkansas 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 - 62141AR0100013-00

Standard On Exchange Plan - 62141AR0100013-01

Open to Indians below 300% FPL - 62141AR0100013-02

Open to Indians above 300% FPL - 62141AR0100013-03

73% AV Silver Plan - 62141AR0100013-04

87% AV Silver Plan - 62141AR0100013-05

94% AV Silver Plan - 62141AR0100013-06

Last Plan Update Date Wed, 18 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan Variant 62141AR0100013-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.709352905
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 Standard Silver Off Exchange Plan
Dental Only Plan No
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 0.9539
First Tier Utilization 100%
Formulary ID ARF006
Formulary URL URL
HIOS Product ID 62141AR010
Import Date 8/18/2021 20:00
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 Yes
Is a Referral Required for Specialist? No
Issuer Actuarial Value 70.94%
Issuer ID 62141
Issuer Marketplace Marketing Name Ambetter from Arkansas Health & Wellness
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 ARN001
Out of Country Coverage No
Out of Service Area Coverage Yes
Out of Service Area Coverage Description PPO Plan - out of network limitations apply
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan ID (Standard Component ID with Variant) 62141AR0100013-00
Plan Marketing Name Ambetter Balanced Care 4 + Vision + Adult Dental
Plan Type PPO
Plan Variant Marketing Name Ambetter Balanced Care 4 + 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 $7,200
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,100
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID ARS001
Source Name SERFF
Plan ID 62141AR0100013
State Code AR
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $39400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $19700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $19,700
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $29400 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $14700 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $14,700
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 $14400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7200 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,200
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $15000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $7500 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $7,500
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $14400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7200 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,200
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $25000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $12500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $12,500
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 4 + Vision + Adult Dental Health Insurance Plan, 62141AR0100013

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

Frequently Asked Questions(FAQ) about Ambetter Balanced Care 4 + Vision + Adult Dental, 62141AR0100013 Health Insurance Plan, 62141AR0100013

  • Does Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan, 62141AR0100013 support Mail Ordering?

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

  • Does (62141AR0100013) Health Insurance Plan, Variant (62141AR0100013-00) offer Disease Management Programs?

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

    Does (62141AR0100013) Health Insurance Plan, Variant (62141AR0100013-00) have Out Of Country Coverage?

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

    Does (62141AR0100013) Health Insurance Plan, Variant (62141AR0100013-00) have Out of Service Area Coverage?

    Yes. Details: PPO Plan - out of network limitations apply

    Does (62141AR0100013) Health Insurance Plan, Variant (62141AR0100013-00) offer Disease Management Programs?

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

    Does Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan, Variant (62141AR0100013-00) offer Disease Management Programs for Asthma?

    Yes, the Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan Variant 62141AR0100013-00 offers Disease Management Program for Asthma.

    Does Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan, Variant (62141AR0100013-00) offer Disease Management Programs for Heart disease?

    Yes, the Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan Variant 62141AR0100013-00 offers Disease Management Program for Heart disease.

    Does Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan, Variant (62141AR0100013-00) offer Disease Management Programs for Diabetes?

    Yes, the Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan Variant 62141AR0100013-00 offers Disease Management Program for Diabetes.

    Does Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan, Variant (62141AR0100013-00) offer Disease Management Programs for Pregnancy?

    Yes, the Ambetter Balanced Care 4 + Vision + Adult Dental Health Insurance Plan Variant 62141AR0100013-00 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