CareSource Marektplace Bronze Dental, Vision, & Fitness - 13591NC0020003 Health Insurance Plan

CareSource North Carolina Co. health insurance plan with the Plan ID 13591NC0020003. The plan is called CareSource Marektplace Bronze Dental, Vision, & Fitness.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 59.86% (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 40.14% 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 13591NC0020003
Health Insurance Plan Year 2023
State North Carolina
Health Insurance Issuer CareSource North Carolina Co.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 13591NC0020003-00
Provider Network(s) ['NCN001']
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 North Carolina 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 - 13591NC0020003-00

Standard On Exchange Plan - 13591NC0020003-01

Open to Indians below 300% FPL - 13591NC0020003-02

Open to Indians above 300% FPL - 13591NC0020003-03

Last Plan Update Date Sat, 25 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan, 13591NC0020003-00

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

Injury as a result of chewing or biting is not considered an accidental injury.

YES

0.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

0.00% Coinsurance after deductible

100.00%
Bariatric Surgery

Bariatric surgery will be available when medically necessary.

YES

0.00% Coinsurance after deductible

100.00%
Basic Dental Care - Adult

$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits.

YES

40.00%

100.00%
Basic Dental Care - Child

See plan documents for details on benefit limits

YES

0.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

0.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 30.0 Visit(s) per Benefit Period

30 visit limits for PT and OT combined (including chiropractic).

YES

0.00% Coinsurance after deductible

100.00%
Cosmetic Surgery

Cosmetic Procedures do not include coverage for procedures or services that change or improve appearance without significantly improving physiological function, other than those mandated by State or Federal law.

NO
Delivery and All Inpatient Services for Maternity Care
YES

0.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Benefit Period

See plan documents for details on benefit limits.

YES

$0.00

100.00%
Diabetes Education
YES

0.00% Coinsurance after deductible

100.00%
Dialysis
YES

0.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

0.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

No Charge after deductible

0.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

Limited to one pair of glasses or contact lenses per benefit year.

YES

$0.00, 0.00%

100.00%
Gender Affirming Care

Surgery determined to be Medically Necessary is Covered

YES

0.00% Coinsurance after deductible

100.00%
Generic Drugs
YES

No Charge after deductible

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Benefit Period

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

YES

0.00% Coinsurance after deductible

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

One hearing aid per hearing impaired ear, and replacement hearing aids for members once every 36 months.

YES

0.00% Coinsurance after deductible

100.00%
Home Health Care Services
YES

0.00% Coinsurance after deductible

100.00%
Hospice Services

Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.

YES

0.00% Coinsurance after deductible

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

No Charge after deductible

100.00%
Infertility Treatment

Limit: 3.0 Treatment(s) per Lifetime

Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member. The lifetime maximums are described in BCBSNC medical policies, which are guides considered by BCBSNC when making coverage determinations.

YES

0.00% Coinsurance after deductible

100.00%
Infusion Therapy
YES

0.00% Coinsurance after deductible

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

No Charge after deductible

100.00%
Inpatient Physician and Surgical Services
YES

0.00% Coinsurance 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

$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits.

YES

50.00%

100.00%
Major Dental Care - Child

See plan documents for details on benefit limits

YES

0.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

No Charge after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

No Charge after deductible

100.00%
Non-Preferred Brand Drugs
YES

No Charge after deductible

100.00%
Nutritional Counseling

Nutritional counseling visits are separate from the obesity-related office visits.

YES

0.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Limited to Medically Necessary Orthodontia. See plan documents for details on benefit limits.

YES

0.00% Coinsurance after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

0.00% Coinsurance after deductible

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

No Charge after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Benefit Period

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

YES

0.00% Coinsurance 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

0.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization

All preventive care that is not state mandated is not covered OON.

YES

0.00%

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

No Charge after deductible

100.00%
Private-Duty Nursing
YES

0.00% Coinsurance after deductible

100.00%
Prosthetic Devices

Prosthetic appliance must replace all or part of a body part or its function. Therapeutic contact lenses may be covered when used as a corneal bandage for a medical condition; benefits include a one-time replacement of eyeglass or contact lenses due to a prescription change after cataract surgery.

YES

0.00% Coinsurance after deductible

100.00%
Radiation
YES

0.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy.

YES

0.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Benefit Period

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

YES

No Charge after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Benefit Period

YES

No Charge after deductible

100.00%
Routine Dental Services (Adult)

Limit: 2.0 Visit(s) per year

$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits.

YES

$0.00

100.00%
Routine Eye Exam (Adult)

Limit: 1.0 Exam(s) per Benefit Period

YES

40.00%

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Benefit Period

YES

$0.00, 0.00%

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

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
YES

No Charge after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

No Charge after deductible

100.00%
Transplant

Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient's coverage.

YES

0.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY.

YES

0.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

No Charge after deductible

0.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

0.00%

100.00%
X-rays and Diagnostic Imaging
YES

No Charge after deductible

100.00%

CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan Variant 13591NC0020003-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.598552346
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 0.98367106
First Tier Utilization 100%
Formulary ID NCF002
Formulary URL URL
HIOS Product ID 13591NC002
Import Date 2/25/2023 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 Yes
Is a Referral Required for Specialist? No
Issuer ID 13591
Issuer Marketplace Marketing Name CareSource
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Bronze
Multiple In Network Tiers No
National Network No
Network ID NCN001
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Services Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Services Only
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 13591NC0020003-00
Plan Marketing Name CareSource Marektplace Bronze Dental, Vision, & Fitness
Plan Type HMO
Plan Variant Marketing Name CareSource Marektplace Bronze Dental, Vision, & Fitness
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 $0
SBC Scenario, Having Diabetes, Deductible $5,400
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID NCS001
Source Name HIOS
Plan ID 13591NC0020003
State Code NC
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $9,100
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $18200 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $9100 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $9,100
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 Yes

Copay & Coinsurance of CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan, 13591NC0020003

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

Frequently Asked Questions(FAQ) about CareSource Marektplace Bronze Dental, Vision, & Fitness, 13591NC0020003 Health Insurance Plan, 13591NC0020003

  • Does CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan, 13591NC0020003 support Mail Ordering?

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

  • Does (13591NC0020003) Health Insurance Plan, Variant (13591NC0020003-00) 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 (13591NC0020003) Health Insurance Plan, Variant (13591NC0020003-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (13591NC0020003) Health Insurance Plan, Variant (13591NC0020003-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services Only

    Does (13591NC0020003) Health Insurance Plan, Variant (13591NC0020003-00) 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 CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan, Variant (13591NC0020003-00) offer Disease Management Programs for Asthma?

    Yes, the CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan Variant 13591NC0020003-00 offers Disease Management Program for Asthma.

    Does CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan, Variant (13591NC0020003-00) offer Disease Management Programs for Heart disease?

    Yes, the CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan Variant 13591NC0020003-00 offers Disease Management Program for Heart disease.

    Does CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan, Variant (13591NC0020003-00) offer Disease Management Programs for Depression?

    Yes, the CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan Variant 13591NC0020003-00 offers Disease Management Program for Depression.

    Does CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan, Variant (13591NC0020003-00) offer Disease Management Programs for Diabetes?

    Yes, the CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan Variant 13591NC0020003-00 offers Disease Management Program for Diabetes.

    Does CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan, Variant (13591NC0020003-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan Variant 13591NC0020003-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan, Variant (13591NC0020003-00) offer Disease Management Programs for Low back pain?

    Yes, the CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan Variant 13591NC0020003-00 offers Disease Management Program for Low back pain.

    Does CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan, Variant (13591NC0020003-00) offer Disease Management Programs for Pregnancy?

    Yes, the CareSource Marektplace Bronze Dental, Vision, & Fitness Health Insurance Plan Variant 13591NC0020003-00 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