Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 - 99129IL0120003 Health Insurance Plan

Aetna Health Inc. (a PA corp.) health insurance plan with the Plan ID 99129IL0120003. The plan is called Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7.

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 99129IL0120003
Health Insurance Plan Year 2023
State Illinois
Health Insurance Issuer Aetna Health Inc. (a PA corp.)
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 99129IL0120003-00
Provider Network(s) ['ILN001']
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 Illinois 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 - 99129IL0120003-00

Standard On Exchange Plan - 99129IL0120003-01

Open to Indians below 300% FPL - 99129IL0120003-02

Open to Indians above 300% FPL - 99129IL0120003-03

Last Plan Update Date Fri, 16 Sep 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan, 99129IL0120003-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited

Abortions are only covered when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest

YES

$100.00

100.00%
Accidental Dental
YES

$100.00

100.00%
Acupuncture

Limit: 10.0 Visit(s) per Year

Exclusions: Coverage is limited to 10 visits per calendar year.

YES

$50.00

100.00%
Allergy Testing
YES

$100.00

100.00%
Autism Spectrum Disorders

Member cost share based on place and type of service.

YES

$50.00

100.00%
Bariatric Surgery

Pre-certification is required. Surgery for obesity will be a Covered Service only when required due to morbid obesity. The participant meets the current NIH (National Institutes of Health) surgical criteria.

YES

50.00% Coinsurance after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Bones/Joints

Member cost share based on place and type of service.

YES

50.00% Coinsurance after deductible

100.00%
Breast Implant Removal

Member cost share based on place and type of service.

YES

50.00% Coinsurance after deductible

100.00%
Chemotherapy

Member cost share based on place and type of service.

YES

50.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 25.0 Visit(s) per Year

Benefits will be provided for manipulation or adjustment of osseous or articular structures, commonly referred to as chiropractic and osteopathic manipulation, when performed by a person licensed to perform such procedures.

YES

$50.00

100.00%
Clinical Trials

Member cost share based on place and type of service.

YES

$100.00

100.00%
Cosmetic Surgery

Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered.

YES

50.00% Coinsurance after deductible

100.00%
Delivery and All Inpatient Services for Maternity Care
YES

50.00% Coinsurance after deductible

100.00%
Dental Anesthesia
YES

50.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Care Management

Member cost share based on place and type of service.

YES

$100.00

100.00%
Diabetes Education

Services must be rendered by a physician, or duly certified, registered or licensed health care professional with expertise in diabetes management.

YES

$100.00

100.00%
Dialysis
YES

50.00% Coinsurance after deductible

100.00%
Durable Medical 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
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Exclusions: Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per year. Age 0-19.

YES

50.00% Coinsurance after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs

Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

$25.00

100.00%
Habilitation Services

Treatment must be medically necessary and therapeutic and not investigational.

YES

50.00% Coinsurance after deductible

100.00%
Hearing Aids

Limit: 2.0 Item(s) per 2 Years

Exclusions: Hearing aids limited to 1 hearing aid per ear every 24 months. Bone anchored hearing aids and cochlear implants are covered.

YES

50.00% Coinsurance after deductible

100.00%
Home Health Care Services
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

Exclusions: Limited to 4 attempts, if live birth, 2 additional attempts covered.

YES

$100.00

100.00%
Infusion Therapy

Member cost share based on place and type of service.

YES

50.00% Coinsurance after deductible

100.00%
Inherited Metabolic Disorder - PKU
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
NO
Mental/Behavioral Health Inpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$50.00

100.00%
Multiple Sclerosis

Member cost share based on place and type of service.

YES

$50.00

100.00%
Non-Preferred Brand Drugs

Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

$100.00 Copay after deductible

100.00%
Nutritional Counseling
YES

No Charge

100.00%
Organ Transplants

Member cost share based on place and type of service. Network benefits must be received within the transplant network.

YES

50.00% Coinsurance after deductible

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

$50.00

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

50.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services
YES

$50.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

$50.00 Copay after deductible

100.00%
Prenatal and Postnatal Care

Member cost sharing applies to postnatal care

YES

50.00% Coinsurance after deductible

100.00%
Prescription Drugs Other

Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

$100.00 Copay after deductible

100.00%
Preventive Care/Screening/Immunization

Exclusions: Age and frequency schedules may apply.

YES

0.00%

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

$50.00

100.00%
Private-Duty Nursing

Exclusions: Inpatient Private Duty Nursing Services are not covered.

YES

50.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

50.00% Coinsurance after deductible

100.00%
Radiation
YES

50.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Member cost share based on place and type of service.

YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Provided when rendered by a registered Occupational Therapist or registered professional Physical Therapist under the supervision of a Physician.

YES

$50.00

100.00%
Rehabilitative Speech Therapy

Provided when rendered by a licensed Speech Therapist or Speech Therapist certified by the American Speech and Hearing Association.

YES

$50.00

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

Limit: 1.0 Exam(s) per Year

Exclusions: Coverage is limited to 1 exam every 12 months age 0-19.

YES

50.00% Coinsurance after deductible

100.00%
Routine Foot Care

Only covered for persons diagnosed with diabetes.

YES

$100.00

100.00%
Skilled Nursing Facility
YES

50.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$100.00

100.00%
Specialty Drugs

Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

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

Member cost share based on place and type of service. Network benefits must be received within the transplant network.

YES

50.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Member cost share based on place and type of service.

YES

50.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$75.00

100.00%
Weight Loss Programs

Online weight loss programs are available.

NO
Well Baby Visits and Care

Exclusions: Children immunizations covered at 100% deductible waived for children up to 72 months of age. Coverage is limited to 7 exams in the first 12 months of life; 3 exams in the second 12 months of life; 3 exams in the third 12 months of life; 1 exam every 12 months thereafter to age 22.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

50.00% Coinsurance after deductible

100.00%

Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan Variant 99129IL0120003-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.6418
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, Pregnancy
EHB Percent of Total Premium 0.9998
First Tier Utilization 100%
Formulary ID ILF030
Formulary URL URL
HIOS Product ID 99129IL012
Import Date 9/16/2022 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment 0
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? Yes
Issuer ID 99129
Issuer Marketplace Marketing Name Aetna CVS Health
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 ILN001
Out of Country Coverage No
Out of Service Area Coverage No
Out of Service Area Coverage Description Except for Emergencies
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 99129IL0120003-00
Plan Marketing Name Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7
Plan Type HMO
Plan Variant Marketing Name Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7
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 $1,200
SBC Scenario, Having Diabetes, Deductible $3,200
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $400
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,900
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID ILS001
Source Name SERFF
Specialist Requiring a Referral Referral required for all physicians EXCEPT PCP, OB/GYN, Pediatrician and MH/SUD providers.
Plan ID 99129IL0120003
State Code IL
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 No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan, 99129IL0120003

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

Frequently Asked Questions(FAQ) about Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7, 99129IL0120003 Health Insurance Plan, 99129IL0120003

  • Does Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan, 99129IL0120003 support Mail Ordering?

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

  • Does (99129IL0120003) Health Insurance Plan, Variant (99129IL0120003-00) 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

    Does (99129IL0120003) Health Insurance Plan, Variant (99129IL0120003-00) have Out Of Country Coverage?

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

    Does (99129IL0120003) Health Insurance Plan, Variant (99129IL0120003-00) 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: Except for Emergencies

    Does (99129IL0120003) Health Insurance Plan, Variant (99129IL0120003-00) 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

    Does Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan, Variant (99129IL0120003-00) offer Disease Management Programs for Asthma?

    Yes, the Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan Variant 99129IL0120003-00 offers Disease Management Program for Asthma.

    Does Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan, Variant (99129IL0120003-00) offer Disease Management Programs for Heart disease?

    Yes, the Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan Variant 99129IL0120003-00 offers Disease Management Program for Heart disease.

    Does Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan, Variant (99129IL0120003-00) offer Disease Management Programs for Depression?

    Yes, the Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan Variant 99129IL0120003-00 offers Disease Management Program for Depression.

    Does Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan, Variant (99129IL0120003-00) offer Disease Management Programs for Diabetes?

    Yes, the Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan Variant 99129IL0120003-00 offers Disease Management Program for Diabetes.

    Does Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan, Variant (99129IL0120003-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan Variant 99129IL0120003-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan, Variant (99129IL0120003-00) offer Disease Management Programs for Low back pain?

    Yes, the Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan Variant 99129IL0120003-00 offers Disease Management Program for Low back pain.

    Does Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan, Variant (99129IL0120003-00) offer Disease Management Programs for Pregnancy?

    Yes, the Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 Health Insurance Plan Variant 99129IL0120003-00 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