Ascension Personalized Care No Deductible Bronze - 35755IN0080004 Health Insurance Plan

US HEALTH AND LIFE INSURANCE COMPANY health insurance plan with the Plan ID 35755IN0080004. The plan is called Ascension Personalized Care No Deductible Bronze.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.74% (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 35.26% 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 35755IN0080004
Health Insurance Plan Year 2023
State Indiana
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 35755IN0080004-00
Provider Network(s) ['INN001']
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 Indiana 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 - 35755IN0080004-00

Standard On Exchange Plan - 35755IN0080004-01

Open to Indians below 300% FPL - 35755IN0080004-02

Open to Indians above 300% FPL - 35755IN0080004-03

Last Plan Update Date Thu, 18 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Ascension Personalized Care No Deductible Bronze Health Insurance Plan, 35755IN0080004-00

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

Limit: 3000.0 Dollars per Episode

The limit will not apply to Outpatient facility charges, anesthesia billed by a Provider other than the Physician performing the service, or to services that we are required by law to cover. Cost share is driven by provider/setting. Limited to $3,000/accident; combined In and Out of network. Benefits for Accidental Dental are based on the setting in which Covered Services are recommended.

YES

50.00%

100.00%
Acupuncture
NO
Allergy Testing

Cost share driven by provider/setting.

YES

$50.00

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

Cost share driven by provider/setting.

YES

50.00%

100.00%
Chiropractic Care

Limit: 12.0 Visit(s) per Benefit Period

Limit combined In and out of network. Cost share driven by provider/setting.

YES

50.00%

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

$2,000.00

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

50.00%

100.00%
Dialysis
YES

50.00%

100.00%
Durable Medical Equipment

One wig per benefit period combined both In and Out of Network. Network and Non-Network for wigs following cancer treatment.

YES

50.00%

100.00%
Emergency Room Services
YES

$1,000.00

$1,000.00
Emergency Transportation/Ambulance
YES

$1,000.00

$1,000.00
Eye Glasses for Children
YES

50.00%

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

$30.00

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Benefit Period

Cost share is driven by provider/setting. Habilitation and rehabilitation visits count toward the rehabilitation limit. PT, OT and ST include an additional 20 visits each for habilitative services. Limits are combined both In and Out of Network.

YES

$100.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 100.0 Visit(s) per Benefit Period

Combined In and out of network. Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home.

YES

50.00%

100.00%
Hospice Services
YES

$2,000.00

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

$200.00

100.00%
Infertility Treatment
NO
Infusion Therapy

Cost share driven by provider/setting.

YES

50.00%

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

Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network.

YES

$2000.00 Copay per Day

100.00%
Inpatient Physician and Surgical Services
YES

No Charge

100.00%
Laboratory Outpatient and Professional Services

Cost share driven by provider/setting.

YES

$50.00

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

$2000.00 Copay per Day

100.00%
Mental/Behavioral Health Outpatient Services

Cost share driven by provider/setting.

YES

$50.00

100.00%
Non-Preferred Brand Drugs
YES

$250.00

100.00%
Nutritional Counseling

Cost share driven by provider/setting.

YES

50.00%

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

$100.00

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

$1,000.00

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Benefit Period

Cost share is driven by provider/setting. Coverage for Speech Therapy is limited to 20 visits per benefit period, Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to 20 visits per benefit period. These limits are combined in and out of network. Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network. Cardiac Rehabilitation limited to 36 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network when rendered in the home, Home Care Services limits apply.Pulmonary Rehabilitation limited to 20 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network. When rendered in the home, Home Care Services limits apply. When rendered as part of physical therapy, the Physical Therapy limit will apply instead of the limit indicated.

YES

$100.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$200.00

100.00%
Preferred Brand Drugs
YES

$150.00

100.00%
Prenatal and Postnatal Care
YES

$50.00

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

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

$50.00

100.00%
Private-Duty Nursing

Limit: 82.0 Visit(s) per Year

YES

50.00%

100.00%
Prosthetic Devices

Must be medically necessary.

YES

50.00%

100.00%
Radiation

Cost share driven by provider/setting.

YES

50.00%

100.00%
Reconstructive Surgery

Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed. Reconstructive services required due to prior therapeutic process are payable only if the original procedure would have been a covered service under this plan.

YES

50.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Benefit Period

Cost share is driven by provider/setting. Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period. Both apply to In-Network Providers and Non-Network Providers combined. Coverage also includes an additional 20 visits each for habilitative services.

YES

$100.00

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Benefit Period

Combined In and out of network. Cost share driven by provider/setting.

YES

$100.00

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

$50.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 90.0 Days per Benefit Period

Limit is combined both In and Out of Network.

YES

$2000.00 Copay per Day

100.00%
Specialist Visit
YES

$100.00

100.00%
Specialty Drugs
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

$2000.00 Copay per Day

100.00%
Substance Abuse Disorder Outpatient Services

Cost share driven by provider/setting.

YES

$50.00

100.00%
Transplant

Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined).

YES

50.00%

100.00%
Treatment for Temporomandibular Joint Disorders
YES

50.00%

100.00%
Urgent Care Centers or Facilities
YES

50.00%

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

No Charge

100.00%
X-rays and Diagnostic Imaging

Cost share driven by provider/setting.

YES

$100.00

100.00%

Ascension Personalized Care No Deductible Bronze Health Insurance Plan Variant 35755IN0080004-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.647399557
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
Drug EHB Deductible, Combined In/Out of Network, Family Per Group $10000 per group
Drug EHB Deductible, Combined In/Out of Network, Family Per Person $5000 per person
Drug EHB Deductible, Combined In/Out of Network, Individual $5,000
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $10000 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $5000 per person
Drug EHB Deductible, In Network (Tier 1), Individual $5,000
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
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 INF004
Formulary URL URL
HIOS Product ID 35755IN008
Import Date 8/18/2022 1:00
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 No
Is a Referral Required for Specialist? No
Issuer ID 35755
Issuer Marketplace Marketing Name US Health and Life
Market Coverage Individual
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Medical EHB Deductible, In Network (Tier 1), Individual $0
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Metal Level Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID INN001
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) 35755IN0080004-00
Plan Marketing Name Ascension Personalized Care No Deductible Bronze
Plan Type EPO
Plan Variant Marketing Name Ascension Personalized Care No Deductible Bronze
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $3,000
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $400
SBC Scenario, Having Diabetes, Copayment $4,000
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $100
SBC Scenario, Treatment of a Simple Fracture, Copayment $2,000
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID INS001
Source Name HIOS
Plan ID 35755IN0080004
State Code IN
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
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 No Deductible Bronze Health Insurance Plan, 35755IN0080004

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

Frequently Asked Questions(FAQ) about Ascension Personalized Care No Deductible Bronze, 35755IN0080004 Health Insurance Plan, 35755IN0080004

  • Does Ascension Personalized Care No Deductible Bronze Health Insurance Plan, 35755IN0080004 support Mail Ordering?

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

  • Does (35755IN0080004) Health Insurance Plan, Variant (35755IN0080004-00) 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 (35755IN0080004) Health Insurance Plan, Variant (35755IN0080004-00) have Out Of Country Coverage?

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

    Does (35755IN0080004) Health Insurance Plan, Variant (35755IN0080004-00) 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 (35755IN0080004) Health Insurance Plan, Variant (35755IN0080004-00) 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 No Deductible Bronze Health Insurance Plan, Variant (35755IN0080004-00) offer Disease Management Programs for Asthma?

    Yes, the Ascension Personalized Care No Deductible Bronze Health Insurance Plan Variant 35755IN0080004-00 offers Disease Management Program for Asthma.

    Does Ascension Personalized Care No Deductible Bronze Health Insurance Plan, Variant (35755IN0080004-00) offer Disease Management Programs for Heart disease?

    Yes, the Ascension Personalized Care No Deductible Bronze Health Insurance Plan Variant 35755IN0080004-00 offers Disease Management Program for Heart disease.

    Does Ascension Personalized Care No Deductible Bronze Health Insurance Plan, Variant (35755IN0080004-00) offer Disease Management Programs for Depression?

    Yes, the Ascension Personalized Care No Deductible Bronze Health Insurance Plan Variant 35755IN0080004-00 offers Disease Management Program for Depression.

    Does Ascension Personalized Care No Deductible Bronze Health Insurance Plan, Variant (35755IN0080004-00) offer Disease Management Programs for Diabetes?

    Yes, the Ascension Personalized Care No Deductible Bronze Health Insurance Plan Variant 35755IN0080004-00 offers Disease Management Program for Diabetes.

    Does Ascension Personalized Care No Deductible Bronze Health Insurance Plan, Variant (35755IN0080004-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Ascension Personalized Care No Deductible Bronze Health Insurance Plan Variant 35755IN0080004-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Ascension Personalized Care No Deductible Bronze Health Insurance Plan, Variant (35755IN0080004-00) offer Disease Management Programs for Pregnancy?

    Yes, the Ascension Personalized Care No Deductible Bronze Health Insurance Plan Variant 35755IN0080004-00 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