CareSource Marketplace Bronze First Dental, Vision, & Fitness - 77552OH0020204 Health Insurance Plan

CareSource Ohio, Inc. health insurance plan with the Plan ID 77552OH0020204. The plan is called CareSource Marketplace Bronze First Dental, Vision, & Fitness.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.92% (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 35.08% 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 77552OH0020204
Health Insurance Plan Year 2022
State Ohio
Health Insurance Issuer CareSource Ohio, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 77552OH0020204-00
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 - 77552OH0020204-00

Standard On Exchange Plan - 77552OH0020204-01

Open to Indians below 300% FPL - 77552OH0020204-02

Open to Indians above 300% FPL - 77552OH0020204-03

Last Plan Update Date Mon, 16 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan Variant 77552OH0020204-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.64921235
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze Off Exchange Plan
Dental Only Plan No
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 0.97837785
First Tier Utilization 100%
Formulary ID OHF002
Formulary URL URL
HIOS Product ID 77552OH002
Import Date 8/16/2021 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 Yes
Is a Referral Required for Specialist? No
Issuer ID 77552
Issuer Marketplace Marketing Name CareSource
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 OHN001
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 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 77552OH0020204-00
Plan Marketing Name CareSource Marketplace Bronze First Dental, Vision, & Fitness
Plan Type HMO
Plan Variant Marketing Name CareSource Marketplace Bronze First Dental, Vision, & Fitness
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,000
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $7,700
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $600
SBC Scenario, Having Diabetes, Deductible $4,000
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 $2,100
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID OHS001
Source Name SERFF
Plan ID 77552OH0020204
State Code OH
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $8,700
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $15400 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $7700 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $7,700
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 $15400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7700 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,700
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 $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
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 Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan, 77552OH0020204

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

Frequently Asked Questions(FAQ) about CareSource Marketplace Bronze First Dental, Vision, & Fitness, 77552OH0020204 Health Insurance Plan, 77552OH0020204

  • Does CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan, 77552OH0020204 support Mail Ordering?

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

  • Does (77552OH0020204) Health Insurance Plan, Variant (77552OH0020204-00) 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 (77552OH0020204) Health Insurance Plan, Variant (77552OH0020204-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (77552OH0020204) Health Insurance Plan, Variant (77552OH0020204-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services Only

    Does (77552OH0020204) Health Insurance Plan, Variant (77552OH0020204-00) 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 Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan, Variant (77552OH0020204-00) offer Disease Management Programs for Asthma?

    Yes, the CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan Variant 77552OH0020204-00 offers Disease Management Program for Asthma.

    Does CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan, Variant (77552OH0020204-00) offer Disease Management Programs for Heart disease?

    Yes, the CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan Variant 77552OH0020204-00 offers Disease Management Program for Heart disease.

    Does CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan, Variant (77552OH0020204-00) offer Disease Management Programs for Depression?

    Yes, the CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan Variant 77552OH0020204-00 offers Disease Management Program for Depression.

    Does CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan, Variant (77552OH0020204-00) offer Disease Management Programs for Diabetes?

    Yes, the CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan Variant 77552OH0020204-00 offers Disease Management Program for Diabetes.

    Does CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan, Variant (77552OH0020204-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan Variant 77552OH0020204-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan, Variant (77552OH0020204-00) offer Disease Management Programs for Low back pain?

    Yes, the CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan Variant 77552OH0020204-00 offers Disease Management Program for Low back pain.

    Does CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan, Variant (77552OH0020204-00) offer Disease Management Programs for Pregnancy?

    Yes, the CareSource Marketplace Bronze First Dental, Vision, & Fitness Health Insurance Plan Variant 77552OH0020204-00 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