Ascension Personalized Care Balanced Bronze 2 - 57125TX0090002 Health Insurance Plan

US HEALTH AND LIFE INSURANCE COMPANY health insurance plan with the Plan ID 57125TX0090002. The plan is called Ascension Personalized Care Balanced Bronze 2.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.33% (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 35.67% 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 57125TX0090002
Health Insurance Plan Year 2023
State Texas
Health Insurance Issuer US HEALTH AND LIFE INSURANCE COMPANY
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 57125TX0090002-00
Provider Network(s) ['TXN001']
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 Texas 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 - 57125TX0090002-00

Standard On Exchange Plan - 57125TX0090002-01

Open to Indians below 300% FPL - 57125TX0090002-02

Open to Indians above 300% FPL - 57125TX0090002-03

Last Plan Update Date Fri, 24 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan, 57125TX0090002-00

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

No Charge after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Chiropractic Care

Limit: 35.0 Visit(s) per Year

Limited to combined 35 visits per year, including Chiropractic.

YES

No Charge after deductible

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

Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.

YES

No Charge after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

No Charge after deductible

100.00%
Dialysis
YES

No Charge after deductible

100.00%
Durable Medical Equipment
YES

No Charge after deductible

100.00%
Emergency Room Services
YES

No Charge after deductible

No Charge after deductible
Emergency Transportation/Ambulance
YES

No Charge after deductible

No Charge after deductible
Eye Glasses for Children
YES

No Charge after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

$15.00

100.00%
Habilitation Services

Limit: 35.0 Visit(s) per Year

Habilitative and rehabilitative limits cannot be combined for plans issued or renewed on or after January 1, 2017. Habilitation services includes autism services, and the benchmark plan does not impose age or maximums on autism coverage.

YES

No Charge after deductible

100.00%
Hearing Aids

To restore or correction of impaired speech or hearing loss.

YES

No Charge after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

YES

No Charge after deductible

100.00%
Hospice Services

Preauthorization is required.

YES

No Charge after deductible

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

No Charge after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

No Charge after deductible

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

All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.

YES

No Charge after deductible

100.00%
Inpatient Physician and Surgical Services
YES

No Charge after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

No Charge after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

Preauthorization is required.

YES

No Charge after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Preauthorization is required.

YES

$25.00

100.00%
Non-Preferred Brand Drugs
YES

No Charge after deductible

100.00%
Nutritional Counseling
NO
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 35.0 Visit(s) per Year

Limited to combined 35 visits per year, including Chiropractic.

YES

No Charge after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge after deductible

100.00%
Preferred Brand Drugs
YES

No Charge after deductible

100.00%
Prenatal and Postnatal Care
YES

$25.00

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$25.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices

Medically necessary foot orthotics are not subject to a calendar year maximum.

YES

No Charge after deductible

100.00%
Radiation
YES

No Charge after deductible

100.00%
Reconstructive Surgery

Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed.

YES

No Charge after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

No Charge after deductible

100.00%
Rehabilitative Speech Therapy
YES

No Charge after deductible

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

$25.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 25.0 Visit(s) per Year

YES

No Charge after deductible

100.00%
Specialist Visit
YES

No Charge after deductible

100.00%
Specialty Drugs
YES

No Charge after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Preauthorization is required.

YES

No Charge after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Certain services require preauthorization.

YES

$25.00

100.00%
Transplant

Preauthorization is required.

YES

No Charge after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Though state law only mandates coverage for temporomandibular joint (TMJ) disorders for large group plans and HMOs, the benchmark plan covers TMJ. Therefore, it is considered part of the EHB package for Texas.

YES

No Charge after deductible

100.00%
Urgent Care Centers or Facilities
YES

No Charge after deductible

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

No Charge after deductible

100.00%

Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan Variant 57125TX0090002-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.643309029
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 Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID TXF002
Formulary URL URL
HIOS Product ID 57125TX009
Import Date 2/24/2023 1:01
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 ID 57125
Issuer Marketplace Marketing Name US Health and Life
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 TXN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 57125TX0090002-00
Plan Marketing Name Ascension Personalized Care Balanced Bronze 2
Plan Type EPO
Plan Variant Marketing Name Ascension Personalized Care Balanced Bronze 2
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $9,100
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $300
SBC Scenario, Having Diabetes, Deductible $4,300
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $10
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID TXS001
Source Name HIOS
Plan ID 57125TX0090002
State Code TX
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 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $18200 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $9100 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $9,100
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 $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,100
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 No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan, 57125TX0090002

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

Frequently Asked Questions(FAQ) about Ascension Personalized Care Balanced Bronze 2, 57125TX0090002 Health Insurance Plan, 57125TX0090002

  • Does Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan, 57125TX0090002 support Mail Ordering?

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

  • Does (57125TX0090002) Health Insurance Plan, Variant (57125TX0090002-00) offer Disease Management Programs?

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

    Does (57125TX0090002) Health Insurance Plan, Variant (57125TX0090002-00) have Out Of Country Coverage?

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

    Does (57125TX0090002) Health Insurance Plan, Variant (57125TX0090002-00) have Out of Service Area Coverage?

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

    Does (57125TX0090002) Health Insurance Plan, Variant (57125TX0090002-00) offer Disease Management Programs?

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

    Does Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan, Variant (57125TX0090002-00) offer Disease Management Programs for Asthma?

    Yes, the Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan Variant 57125TX0090002-00 offers Disease Management Program for Asthma.

    Does Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan, Variant (57125TX0090002-00) offer Disease Management Programs for Heart disease?

    Yes, the Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan Variant 57125TX0090002-00 offers Disease Management Program for Heart disease.

    Does Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan, Variant (57125TX0090002-00) offer Disease Management Programs for Depression?

    Yes, the Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan Variant 57125TX0090002-00 offers Disease Management Program for Depression.

    Does Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan, Variant (57125TX0090002-00) offer Disease Management Programs for Diabetes?

    Yes, the Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan Variant 57125TX0090002-00 offers Disease Management Program for Diabetes.

    Does Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan, Variant (57125TX0090002-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan Variant 57125TX0090002-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan, Variant (57125TX0090002-00) offer Disease Management Programs for Pregnancy?

    Yes, the Ascension Personalized Care Balanced Bronze 2 Health Insurance Plan Variant 57125TX0090002-00 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