Ascension Personalized Care No Deductible Bronze - 57125TX0090004 Health Insurance Plan

US HEALTH AND LIFE INSURANCE COMPANY health insurance plan with the Plan ID 57125TX0090004. 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 57125TX0090004
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 57125TX0090004-00
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 - 57125TX0090004-00

Standard On Exchange Plan - 57125TX0090004-01

Open to Indians below 300% FPL - 57125TX0090004-02

Open to Indians above 300% FPL - 57125TX0090004-03

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 No Deductible Bronze Health Insurance Plan, 57125TX0090004-00

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

50.00%

100.00%
Acupuncture
NO
Allergy Testing
YES

$50.00

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

50.00%

100.00%
Chiropractic Care

Limit: 35.0 Visit(s) per Year

Limited to combined 35 visits per year, including Chiropractic.

YES

50.00%

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

$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
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: 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

$100.00

100.00%
Hearing Aids

To restore or correction of impaired speech or hearing loss.

YES

50.00%

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

YES

50.00%

100.00%
Hospice Services

Preauthorization is required.

YES

$2,000.00

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

$200.00

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

50.00%

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

$2000.00 Copay per Day

100.00%
Inpatient Physician and Surgical Services
YES

No Charge

100.00%
Laboratory Outpatient and Professional Services
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

Preauthorization is required.

YES

$2000.00 Copay per Day

100.00%
Mental/Behavioral Health Outpatient Services

Preauthorization is required.

YES

$50.00

100.00%
Non-Preferred Brand Drugs
YES

$250.00

100.00%
Nutritional Counseling
NO
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: 35.0 Visit(s) per Year

Limited to combined 35 visits per year, including Chiropractic.

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
NO
Prosthetic Devices

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

YES

50.00%

100.00%
Radiation
YES

50.00%

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

50.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

$100.00

100.00%
Rehabilitative Speech Therapy
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: 25.0 Visit(s) per Year

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

Preauthorization is required.

YES

$2000.00 Copay per Day

100.00%
Substance Abuse Disorder Outpatient Services

Certain services require preauthorization.

YES

$50.00

100.00%
Transplant

Preauthorization is required.

YES

50.00%

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

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
YES

$100.00

100.00%

Ascension Personalized Care No Deductible Bronze Health Insurance Plan Variant 57125TX0090004-00 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 TXF004
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 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 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) 57125TX0090004-00
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 TXS001
Source Name HIOS
Plan ID 57125TX0090004
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
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, 57125TX0090004

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, 57125TX0090004 Health Insurance Plan, 57125TX0090004

  • Does Ascension Personalized Care No Deductible Bronze Health Insurance Plan, 57125TX0090004 support Mail Ordering?

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

  • Does (57125TX0090004) Health Insurance Plan, Variant (57125TX0090004-00) 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 (57125TX0090004) Health Insurance Plan, Variant (57125TX0090004-00) have Out Of Country Coverage?

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

    Does (57125TX0090004) Health Insurance Plan, Variant (57125TX0090004-00) 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 (57125TX0090004) Health Insurance Plan, Variant (57125TX0090004-00) 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 (57125TX0090004-00) offer Disease Management Programs for Asthma?

    Yes, the Ascension Personalized Care No Deductible Bronze Health Insurance Plan Variant 57125TX0090004-00 offers Disease Management Program for Asthma.

    Does Ascension Personalized Care No Deductible Bronze Health Insurance Plan, Variant (57125TX0090004-00) offer Disease Management Programs for Heart disease?

    Yes, the Ascension Personalized Care No Deductible Bronze Health Insurance Plan Variant 57125TX0090004-00 offers Disease Management Program for Heart disease.

    Does Ascension Personalized Care No Deductible Bronze Health Insurance Plan, Variant (57125TX0090004-00) offer Disease Management Programs for Depression?

    Yes, the Ascension Personalized Care No Deductible Bronze Health Insurance Plan Variant 57125TX0090004-00 offers Disease Management Program for Depression.

    Does Ascension Personalized Care No Deductible Bronze Health Insurance Plan, Variant (57125TX0090004-00) offer Disease Management Programs for Diabetes?

    Yes, the Ascension Personalized Care No Deductible Bronze Health Insurance Plan Variant 57125TX0090004-00 offers Disease Management Program for Diabetes.

    Does Ascension Personalized Care No Deductible Bronze Health Insurance Plan, Variant (57125TX0090004-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Ascension Personalized Care No Deductible Bronze Health Insurance Plan Variant 57125TX0090004-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Ascension Personalized Care No Deductible Bronze Health Insurance Plan, Variant (57125TX0090004-00) offer Disease Management Programs for Pregnancy?

    Yes, the Ascension Personalized Care No Deductible Bronze Health Insurance Plan Variant 57125TX0090004-00 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