AultCare Silver 5000 No Pediatric Dental - 28162OH0060011 Health Insurance Plan

AultCare Insurance Company health insurance plan with the Plan ID 28162OH0060011. The plan is called AultCare Silver 5000 No Pediatric Dental.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.86% (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 28.14% 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 28162OH0060011
Health Insurance Plan Year 2023
State Ohio
Health Insurance Issuer AultCare Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 28162OH0060011-00
Provider Network(s) ['OHN001']
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 Ohio 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 - 28162OH0060011-00

Standard On Exchange Plan - 28162OH0060011-01

Open to Indians below 300% FPL - 28162OH0060011-02

Open to Indians above 300% FPL - 28162OH0060011-03

73% AV Silver Plan - 28162OH0060011-04

87% AV Silver Plan - 28162OH0060011-05

94% AV Silver Plan - 28162OH0060011-06

Last Plan Update Date Wed, 17 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of AultCare Silver 5000 No Pediatric Dental Health Insurance Plan, 28162OH0060011-00

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

Limit: 3000.0 Dollars per Episode

Quantitative Limit represents established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply. Coverage for dental services resulting from an accidental injury when treatment is performed within 12 months after the injury. The benefit limit will not apply to outpatient facility charges, anesthesia billed by a provider other than the physician performing the service, or to covered services required by law; coverage includes oral examinations, x-rays, tests and laboratory examinations, restorations, prosthetic services, oral surgery, mandibular/maxillary reconstruction, anesthesia and include facility charges for outpatient services for the removal of teeth or for other dental processes if the patient?s medical condition or the dental procedure requires a hospital setting to ensure the safety of the patient.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Chiropractic Care

Limit: 12.0 Treatment(s) per Benefit Period

Benefit limit applies for Osteopathic/Chiropractic Manipulation Therapy.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Prenatal Care.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Dental Check-Up for Children
NO
Diabetes Education

Diabetes Self-Management Training for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Dialysis

Benefits include supportive use of an artificial kidney machine.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Durable Medical Equipment

Covered services include durable medical equipment, medical devices and supplies, prosthetics and appliances, including cochlear implants and eyeglasses/contact lenses (for cataract surgery or injury), and medical/surgical supplies and equipment that serve only a medical purpose for the management of disease. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period; (as required by the Women?s Health and Cancer Rights Act); Left Ventricular Artificial Devices (LVAD) covered only as bridge to heart transplant.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Emergency Room Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Ambulance Services are transportation by a vehicle (including ground, water, fixed wing and rotary wing air transportation) designed, equipped and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals: from home, scene of accident or medical emergency to a hospital; between hospitals; between a hospital and skilled nursing facility; or from a hospital or skilled nursing facility to home; ambulance trips must be made to the closest facility that can give covered services appropriate for the member's condition.

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Gender Affirming Care
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Generic Drugs

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.

YES

$10.00

$10.00
Habilitation Services

Limits may apply to some services; includes benefits for health care services and devices that help a person keep, learn or improve skills and functioning for daily living, including treatment of Autism Spectrum Disorders, which at a minimum shall include: (1) Out-Patient Physical Rehabilitation Services including (a) Speech and Language therapy and/or Occupational therapy, 20 visits per year of each service; and (b) Clinical Therapeutic Intervention, which include but are not limited to Applied Behavioral Analysis, 20 hours per week; and (2) Mental/Behavioral Health Outpatient Services to provide consultation, assessment, development and oversight of treatment plans.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Hearing Aids
NO
Home Health Care Services

Limit: 100.0 Visit(s) per Benefit Period

When therapy services are provided in the home (including physical, speech, and occupational therapy) as part of home health care services, they are not subject to separate visit limits for therapy services. The 100 visit/year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Hospice Services

To be eligible for Hospice benefits, the patient must have a life expectancy of six months or less, as confirmed by the attending Physician.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Infertility Treatment

Infertility and voluntary family planning services are required benefits under state law for HMO plans only per ORC section 1751.01 (A)(1)(h), and must be provided in accordance with Ohio Department of Insurance Bulletin No. 2009-07.

NO
Infusion Therapy

Home IV therapy includes but is not limited to: injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)

There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services; and ancillary (related) services.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Inpatient Physician and Surgical Services

There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient medical care visits limited to one visit per day by any one physician.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Non-Preferred Brand Drugs

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.

YES

40.00%

40.00%
Nutritional Counseling

Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services (includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors). Preventive Services Nutritional Counseling to prevent obesity in chIldren and to prevent cardiovascular disease in adults with cardiovascular risk factors is limited to a total of 4 visits per benefit period.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)

The first 4 primary care doctor and specialist office visits combined are not subject to the deductible or coinsurance. Each of the first 4 office visits combined are subject to the appropriate copayment for primary care physician and/or specialists. Starting with the 5th visit, the deductible and coinsurance will apply.

YES

$35.00 Copay with deductible

60.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document; benefits for facility charges for Outpatient Services are payable for the removal of teeth or for other dental processes only if the patient?s medical condition or the dental procedure requires a Hospital setting to ensure the safety of the patient

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Outpatient Rehabilitation Services

Limit: 116.0 Visit(s) per Benefit Period

Therapy Services rendered in the home as part of Home Care Services will be subject to the Home Care Services visit limits; outpatient rehabilitation services visit limits will not apply. If different types of Therapy Services are performed during one Physician Home Visit, Office Service, or Outpatient Service, then each different type of Therapy Service performed will be considered a separate Therapy Visit. Each Therapy Visit will count against the applicable maximum visits per Benefit Period listed below: Physical and Occupational Therapy limited to 40 visits combined. Speech Therapy limited to 20 visits. Cardiac Rehabilitation limited to 36 visits. Pulmonary Rehabilitation limited to 20 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply. Benefit also includes Physical Medicine and Rehabilitation Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services

See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Preferred Brand Drugs

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.

YES

30.00%

30.00%
Prenatal and Postnatal Care

Includes post-delivery follow-up care performed, by a physician or nurse, within 72 hours of discharge, through home health care visits or, at patient?s discretion, in a medical setting. This coverage includes, but is not limited to parent education; assistance and training in breast or bottle feeding; and routine maternal or neonatal tests and screening (including collection of sample for hereditary and metabolic newborn screening).

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Preventive Care/Screening/Immunization

Services with an 'A' or 'B' rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration including: women?s contraceptives, sterilization procedures, and counseling; breastfeeding support, supplies, and counseling (benefits for breast pumps are limited to one pump per benefit period); and gestational diabetes screening; routine screening mammograms; routine cytologic screening; child health supervision services from birth to age 9.

YES

0.00%

60.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness

The first 4 primary care doctor and specialist office visits combined are not subject to the deductible or coinsurance. Each of the first 4 office visits combined are subject to the appropriate copayment for primary care physician and/or specialists. Starting with the 5th visit, the deductible and coinsurance will apply.

YES

$35.00 Copay with deductible

60.00% Coinsurance after deductible
Private-Duty Nursing

Limit: 90.0 Visit(s) per Benefit Period

Private Duty Nursing Services are Covered Services only when provided through the Home Care Services benefit; Quantitative Limit has been determined as 90 - 110 visits per year and represents the number of visits to meet the established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Prosthetic Devices

Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that 1) Replace all or part of a missing body part and its adjoining tissues; or 2) Replace all or part of the function of a permanently useless or malfunctioning body part.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Radiation
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Reconstructive Surgery

Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Benefit Period

Physical and Occupational Therapy limited to 40 visits combined per benefit period.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Benefit Period

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits.

YES

0.00%

60.00% Coinsurance after deductible
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 90.0 Days per Benefit Period

Benefits include Items and services provided as an inpatient in a skilled nursing bed of skilled nursing facility or hospital, including room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Specialist Visit

The first 4 primary care doctor and specialist office visits combined are not subject to the deductible or coinsurance. Each of the first 4 office visits combined are subject to the appropriate copayment for primary care physician and/or specialists. Starting with the 5th visit, the deductible and coinsurance will apply.

YES

$50.00 Copay with deductible

60.00% Coinsurance after deductible
Specialty Drugs

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.

YES

50.00%

50.00%
Substance Abuse Disorder Inpatient Services

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
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). Transplant benefits apply to any medically necessary human organ and stem cell/bone marrow transplants and transfusions including necessary acquisition procedures, harvest and storage, necessary preparatory myeloablative therapy, and initial evaluation/testing to determine eligibility as a transplant candidate.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders

Benefits provided for temporomandibular (joint connecting the lower jaw to the temporal bone at the side of the head) and craniomandibular (head and neck muscle) disorders.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Urgent Care Centers or Facilities
YES

$75.00

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

0.00%

60.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible

AultCare Silver 5000 No Pediatric Dental Health Insurance Plan Variant 28162OH0060011-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.718570109
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 4
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Silver Off Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Drug EHB Deductible, In Network (Tier 1), Individual $0
Drug EHB Deductible, Out of Network, Family Per Group $0 per group
Drug EHB Deductible, Out of Network, Family Per Person $0 per person
Drug EHB Deductible, Out of Network, Individual $0
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID OHF001
Formulary URL URL
HIOS Product ID 28162OH006
Import Date 8/17/2022 20:01
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 28162
Issuer Marketplace Marketing Name AultCare Insurance Company
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 40.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $10000 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $5000 per person
Medical EHB Deductible, In Network (Tier 1), Individual $5,000
Medical EHB Deductible, Out of Network, Family Per Group $30000 per group
Medical EHB Deductible, Out of Network, Family Per Person $15000 per person
Medical EHB Deductible, Out of Network, Individual $15,000
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID OHN001
Out of Country Coverage Yes
Out of Country Coverage Description Generally, we may pay for limited Emergency Services that are necessary when You are traveling out of the USA, unless you are expressly traveling on business on behalf of Your Employer. We will consider each Claim carefully. We will not pay for Services when You go to another Country to obtain medical care. We do not pay for air transport or medical evacuation. We recommend that You obtain separate medical travel and evacuation insurance if You Plan to travel out of the USA.
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Out of Service Area coverage from a network provider would be provided according to the plan benefits. Out of Service Area coverage from a Non-Network provider would be covered at the Non-Network plan benefits and the member would be responsible for any amounts exceeding plan limitations.
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 28162OH0060011-00
Plan Marketing Name AultCare Silver 5000 No Pediatric Dental
Plan Type PPO
Plan Variant Marketing Name AultCare Silver 5000 No Pediatric Dental
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 $5,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $940
SBC Scenario, Having Diabetes, Copayment $370
SBC Scenario, Having Diabetes, Deductible $1,140
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $110
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,590
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID OHS001
Source Name SERFF
Plan ID 28162OH0060011
State Code OH
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 $13000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $6500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $6,500
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $54600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $27300 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $27,300
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of AultCare Silver 5000 No Pediatric Dental Health Insurance Plan, 28162OH0060011

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

Frequently Asked Questions(FAQ) about AultCare Silver 5000 No Pediatric Dental, 28162OH0060011 Health Insurance Plan, 28162OH0060011

  • Does AultCare Silver 5000 No Pediatric Dental Health Insurance Plan, 28162OH0060011 support Mail Ordering?

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

  • Does (28162OH0060011) Health Insurance Plan, Variant (28162OH0060011-00) 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, Pregnancy, Weight Loss Programs

    Does (28162OH0060011) Health Insurance Plan, Variant (28162OH0060011-00) have Out Of Country Coverage?

    Yes. Details: Generally, we may pay for limited Emergency Services that are necessary when You are traveling out of the USA, unless you are expressly traveling on business on behalf of Your Employer. We will consider each Claim carefully. We will not pay for Services when You go to another Country to obtain medical care. We do not pay for air transport or medical evacuation. We recommend that You obtain separate medical travel and evacuation insurance if You Plan to travel out of the USA.

    Does (28162OH0060011) Health Insurance Plan, Variant (28162OH0060011-00) have Out of Service Area Coverage?

    Yes. Details: Out of Service Area coverage from a network provider would be provided according to the plan benefits. Out of Service Area coverage from a Non-Network provider would be covered at the Non-Network plan benefits and the member would be responsible for any amounts exceeding plan limitations.

    Does (28162OH0060011) Health Insurance Plan, Variant (28162OH0060011-00) 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, Pregnancy, Weight Loss Programs

    Does AultCare Silver 5000 No Pediatric Dental Health Insurance Plan, Variant (28162OH0060011-00) offer Disease Management Programs for Asthma?

    Yes, the AultCare Silver 5000 No Pediatric Dental Health Insurance Plan Variant 28162OH0060011-00 offers Disease Management Program for Asthma.

    Does AultCare Silver 5000 No Pediatric Dental Health Insurance Plan, Variant (28162OH0060011-00) offer Disease Management Programs for Heart disease?

    Yes, the AultCare Silver 5000 No Pediatric Dental Health Insurance Plan Variant 28162OH0060011-00 offers Disease Management Program for Heart disease.

    Does AultCare Silver 5000 No Pediatric Dental Health Insurance Plan, Variant (28162OH0060011-00) offer Disease Management Programs for Depression?

    Yes, the AultCare Silver 5000 No Pediatric Dental Health Insurance Plan Variant 28162OH0060011-00 offers Disease Management Program for Depression.

    Does AultCare Silver 5000 No Pediatric Dental Health Insurance Plan, Variant (28162OH0060011-00) offer Disease Management Programs for Diabetes?

    Yes, the AultCare Silver 5000 No Pediatric Dental Health Insurance Plan Variant 28162OH0060011-00 offers Disease Management Program for Diabetes.

    Does AultCare Silver 5000 No Pediatric Dental Health Insurance Plan, Variant (28162OH0060011-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the AultCare Silver 5000 No Pediatric Dental Health Insurance Plan Variant 28162OH0060011-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does AultCare Silver 5000 No Pediatric Dental Health Insurance Plan, Variant (28162OH0060011-00) offer Disease Management Programs for Low back pain?

    Yes, the AultCare Silver 5000 No Pediatric Dental Health Insurance Plan Variant 28162OH0060011-00 offers Disease Management Program for Low back pain.

    Does AultCare Silver 5000 No Pediatric Dental Health Insurance Plan, Variant (28162OH0060011-00) offer Disease Management Programs for Pregnancy?

    Yes, the AultCare Silver 5000 No Pediatric Dental Health Insurance Plan Variant 28162OH0060011-00 offers Disease Management Program for Pregnancy.

    Does AultCare Silver 5000 No Pediatric Dental Health Insurance Plan, Variant (28162OH0060011-00) offer Disease Management Programs for Weight loss programs?

    Yes, the AultCare Silver 5000 No Pediatric Dental Health Insurance Plan Variant 28162OH0060011-00 offers Disease Management Program for Weight loss programs.

 

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