Anthem HealthKeepers Bronze X 7500 Standard - 88380VA0720044 Health Insurance Plan

HealthKeepers, Inc. health insurance plan with the Plan ID 88380VA0720044. The plan is called Anthem HealthKeepers Bronze X 7500 Standard .

Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.18% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.82% 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 64.18% (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 35.82% 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 88380VA0720044
Health Insurance Plan Year 2023
State Virginia
Health Insurance Issuer HealthKeepers, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 88380VA0720044-00
Provider Network(s) ['VAN001']
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 Virginia 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 - 88380VA0720044-00

Standard On Exchange Plan - 88380VA0720044-01

Open to Indians below 300% FPL - 88380VA0720044-02

Open to Indians above 300% FPL - 88380VA0720044-03

Last Plan Update Date Wed, 25 Jan 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Anthem HealthKeepers Bronze X 7500 Standard Health Insurance Plan, 88380VA0720044-00

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

Treatment must begin within 12 months of the injury, or as soon after that as possible, to be covered. Cost-Share(s) determined based on type of service and place of service rendered.

YES

$100.00

100.00%
Acupuncture
NO
Allergy Testing
YES

50.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

40.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

50.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 30.0 Visit(s) per Benefit Period

Rehabilitative Chiropractic care / spinal manipulation is limited to 30 visits per benefit period. Habilitative Chiropractic care / spinal manipulation is limited to 30 visits per year. Habilitation service limits are not combined with Rehabilitative service limits.

YES

50.00% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

This benefit is for the hospital stay.

YES

50.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Year

Limited to 2 visits per year.

YES

No Charge after deductible

100.00%
Diabetes Education

Cost-Share(s) determined based on type of service and place of service rendered.

YES

$100.00

100.00%
Dialysis
YES

50.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Coverage for ongoing rental of equipment may be limited to the cost of purchasing the equipment.

YES

50.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Benefits for Non-Emergency ambulance services when services have been pre-authorized by Anthem will be limited to $50,000 per occurrence if a Non-Network Provider is used. Includes medically necessary transportation to the nearest appropriate hospital for a medical emergency, or between hospitals or other approved facilities. Includes ground, water, fixed wing and rotary air transportation. Benefits also include medically necessary treatment of a sickness or injury by medical professionals from an ambulance service, even if you are not taken to a facility. Benefits are only available for air ambulance when it is not appropriate to use a ground or water ambulance.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Includes a choice of eyeglasses lenses or contact lenses within a benefit period. Covered eyeglasses lenses include standard plastic lenses in: Single vision, Bifocal, Trifocal, and Standard Progressive. Members choose from a limited frame selection. Coverage for contact lenses includes elective or non-elective contact lenses. Non-elective contact lenses are covered only for certain medical conditions. Limited to 1 item per year.

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.

YES

$25.00

100.00%
Habilitation Services

Habilitation Speech therapy limited to 30 visits per year. Habilitative Physical therapy and Occupational therapy have a combined limit of 30 visits per benefit period. Habilitative service limits are not combined with Rehabilitation service limits. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.

YES

$50.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 100.0 Visit(s) per Benefit Period

The Home Care visit limit will apply instead of the Therapy Services limits for physical, occupational, speech therapy, or cardiac rehabilitation for therapy in the home. Visit limit does not apply to home infusion therapy or home dialysis. Limited to 100 visits per benefit period.

YES

50.00% Coinsurance after deductible

100.00%
Hospice Services
YES

50.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

50.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

50.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

50.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

50.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$50.00

100.00%
Non-Preferred Brand Drugs

30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.

YES

$100.00 Copay after deductible

100.00%
Nutritional Counseling
YES

$50.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Orthodontic Fixed Appliance Therapy, which is treatment that uses an appliance that is cemented or bonded to the teeth, is covered only once per lifetime for Dentally Necessary Coverage only.

YES

50.00% Coinsurance after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)

You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our mobile application, website, or HealthKeepers enabled device.

YES

$50.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

50.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Benefit Period

Rehabilitation Speech therapy limited to 30 visits per year. Rehabilitative Physical therapy and Occupational therapy have a combined limit of 30 visits per benefit period. Rehabilitative service limits are not combined with Habilitation service limits. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.

YES

$50.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.

YES

$50.00 Copay after deductible

100.00%
Prenatal and Postnatal Care
YES

50.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization

You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness

Copay is for Primary Care office visits, Mental Health and Substance Use Office Visits, and Physical, Occupational and Speech Therapies. Other services provided during the visit are subject to additional cost shares. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our mobile application, website, or HealthKeepers enabled device. Doctor Visits in the Home are covered.

YES

$50.00

100.00%
Private-Duty Nursing

Limit: 16.0 Hours per Benefit Period

Private-Duty nursing in a home setting only. Limited to 16 hours per benefit period.

YES

50.00% Coinsurance after deductible

100.00%
Prosthetic Devices

The coinsurance for prosthetics for limb replacement can be no greater than 30%. Per the mandate "Limb" means an arm, a hand, a leg, a foot, or any portion of an arm, a hand, a leg, or a foot. All other prosthetic services are covered under the plan's base coinsurance (Coinsurance formula: If plan coinsurance is greater than 30% then coinsurance for Prosthetics for Limb Replacement is 30%. If plan coinsurance is equal to a less than 30% then consurance for Prosthetics for Limb Replacement, should be the plan coinsurance).

YES

50.00% Coinsurance after deductible

100.00%
Radiation
YES

50.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Benefit Period

Rehabilitation Physical therapy and Occupational therapy limited to 30 visits per benefit period combined. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. Rehabilitative service limits are not combined with Habilitation service limits.

YES

$50.00

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Benefit Period

Rehabilitation Speech therapy limited to 30 visits per benefit period. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. Rehabilitative service limits are not combined with Habilitation service limits.

YES

$50.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Benefit Period

Includes complete eye exam with dilation, as needed to check all aspects of vision, including the structure of the eyes. Limited to 1 visit per year.

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 100.0 Days per Stay

Limited to 100 days per stay.

YES

50.00% Coinsurance after deductible

100.00%
Specialist Visit

Copays do apply to Specialists Visits. Other services provided during the visit are subject to additional cost shares. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our mobile application, website, or HealthKeepers enabled device.

YES

$100.00

100.00%
Specialty Drugs

30 day supply. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.

YES

$500.00 Copay after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$50.00

100.00%
Transplant

Unrelated Donor Search limited to a maximum of the 10 best matched donors, identified by an authorized registry. Medically Necessary charges for the procurement of an organ from a live donor are covered up to the maximum allowed amount, including complications from the donor procedure for up to six weeks from the date of procurement.

YES

50.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

50.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$75.00

$75.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

50.00% Coinsurance after deductible

100.00%

Anthem HealthKeepers Bronze 7500 Standard Health Insurance Plan Variant 88380VA0720044-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.641786747
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 Standard Bronze Off Exchange Plan
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID VAF016
Formulary URL URL
HIOS Product ID 88380VA072
Import Date 1/25/2023 20:01
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 Actuarial Value 64.18%
Issuer ID 88380
Issuer Marketplace Marketing Name HealthKeepers, Inc.
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 VAN001
Out of Country Coverage No
Out of Country Coverage Description Urgent/Emergency Coverage Only
Out of Service Area Coverage No
Out of Service Area Coverage Description TRAD/PAR network
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 88380VA0720044-00
Plan Marketing Name Anthem HealthKeepers Bronze X 7500 Standard
Plan Type HMO
Plan Variant Marketing Name Anthem HealthKeepers Bronze 7500 Standard
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,500
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $7,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $700
SBC Scenario, Having Diabetes, Deductible $4,000
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $500
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,100
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID VAS003
Source Name SERFF
Plan ID 88380VA0720044
State Code VA
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 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $15000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,500
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 $18000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,000
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 Anthem HealthKeepers Bronze X 7500 Standard Health Insurance Plan, 88380VA0720044

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

Frequently Asked Questions(FAQ) about Anthem HealthKeepers Bronze X 7500 Standard , 88380VA0720044 Health Insurance Plan, 88380VA0720044

  • Does Anthem HealthKeepers Bronze X 7500 Standard Health Insurance Plan, 88380VA0720044 support Mail Ordering?

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

  • Does (88380VA0720044) Health Insurance Plan, Variant (88380VA0720044-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management

    Does (88380VA0720044) Health Insurance Plan, Variant (88380VA0720044-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan). Details: Urgent/Emergency Coverage Only

    Does (88380VA0720044) Health Insurance Plan, Variant (88380VA0720044-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: TRAD/PAR network

    Does (88380VA0720044) Health Insurance Plan, Variant (88380VA0720044-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management

    Does Anthem HealthKeepers Bronze 7500 Standard Health Insurance Plan, Variant (88380VA0720044-00) offer Disease Management Programs for Asthma?

    Yes, the Anthem HealthKeepers Bronze 7500 Standard Health Insurance Plan Variant 88380VA0720044-00 offers Disease Management Program for Asthma.

    Does Anthem HealthKeepers Bronze 7500 Standard Health Insurance Plan, Variant (88380VA0720044-00) offer Disease Management Programs for Heart disease?

    Yes, the Anthem HealthKeepers Bronze 7500 Standard Health Insurance Plan Variant 88380VA0720044-00 offers Disease Management Program for Heart disease.

    Does Anthem HealthKeepers Bronze 7500 Standard Health Insurance Plan, Variant (88380VA0720044-00) offer Disease Management Programs for Depression?

    Yes, the Anthem HealthKeepers Bronze 7500 Standard Health Insurance Plan Variant 88380VA0720044-00 offers Disease Management Program for Depression.

    Does Anthem HealthKeepers Bronze 7500 Standard Health Insurance Plan, Variant (88380VA0720044-00) offer Disease Management Programs for Diabetes?

    Yes, the Anthem HealthKeepers Bronze 7500 Standard Health Insurance Plan Variant 88380VA0720044-00 offers Disease Management Program for Diabetes.

    Does Anthem HealthKeepers Bronze 7500 Standard Health Insurance Plan, Variant (88380VA0720044-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Anthem HealthKeepers Bronze 7500 Standard Health Insurance Plan Variant 88380VA0720044-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Anthem HealthKeepers Bronze 7500 Standard Health Insurance Plan, Variant (88380VA0720044-00) offer Disease Management Programs for Low back pain?

    Yes, the Anthem HealthKeepers Bronze 7500 Standard Health Insurance Plan Variant 88380VA0720044-00 offers Disease Management Program for Low back pain.

 

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