CareSource Marketplace Gold - 54192IN0010012 Health Insurance Plan

CareSource Indiana, Inc. health insurance plan with the Plan ID 54192IN0010012. The plan is called CareSource Marketplace Gold.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.62% (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 20.38% 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 54192IN0010012
Health Insurance Plan Year 2022
State Indiana
Health Insurance Issuer CareSource Indiana, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 54192IN0010012-00
Provider Network(s) ['INN001']
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 Indiana 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 - 54192IN0010012-00

Standard On Exchange Plan - 54192IN0010012-01

Open to Indians below 300% FPL - 54192IN0010012-02

Open to Indians above 300% FPL - 54192IN0010012-03

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

CareSource Marketplace Gold Health Insurance Plan Variant 54192IN0010012-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.796177988
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 Gold 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 1
First Tier Utilization 100%
Formulary ID INF003
Formulary URL URL
HIOS Product ID 54192IN001
Import Date 8/12/2021 1:01
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 54192
Issuer Marketplace Marketing Name CareSource
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID INN001
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) 54192IN0010012-00
Plan Marketing Name CareSource Marketplace Gold
Plan Type HMO
Plan Variant Marketing Name CareSource Marketplace Gold
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,100
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $2,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $400
SBC Scenario, Having Diabetes, Copayment $400
SBC Scenario, Having Diabetes, Deductible $2,000
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $20
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,000
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID INS001
Source Name HIOS
Plan ID 54192IN0010012
State Code IN
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $13000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $6500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $6,500
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $4000 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $2000 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $2,000
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $4000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $2000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $2,000
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 $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 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 Gold Health Insurance Plan, 54192IN0010012

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

Frequently Asked Questions(FAQ) about CareSource Marketplace Gold, 54192IN0010012 Health Insurance Plan, 54192IN0010012

  • Does CareSource Marketplace Gold Health Insurance Plan, 54192IN0010012 support Mail Ordering?

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

  • Does (54192IN0010012) Health Insurance Plan, Variant (54192IN0010012-00) 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 (54192IN0010012) Health Insurance Plan, Variant (54192IN0010012-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (54192IN0010012) Health Insurance Plan, Variant (54192IN0010012-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services Only

    Does (54192IN0010012) Health Insurance Plan, Variant (54192IN0010012-00) 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 Gold Health Insurance Plan, Variant (54192IN0010012-00) offer Disease Management Programs for Asthma?

    Yes, the CareSource Marketplace Gold Health Insurance Plan Variant 54192IN0010012-00 offers Disease Management Program for Asthma.

    Does CareSource Marketplace Gold Health Insurance Plan, Variant (54192IN0010012-00) offer Disease Management Programs for Heart disease?

    Yes, the CareSource Marketplace Gold Health Insurance Plan Variant 54192IN0010012-00 offers Disease Management Program for Heart disease.

    Does CareSource Marketplace Gold Health Insurance Plan, Variant (54192IN0010012-00) offer Disease Management Programs for Depression?

    Yes, the CareSource Marketplace Gold Health Insurance Plan Variant 54192IN0010012-00 offers Disease Management Program for Depression.

    Does CareSource Marketplace Gold Health Insurance Plan, Variant (54192IN0010012-00) offer Disease Management Programs for Diabetes?

    Yes, the CareSource Marketplace Gold Health Insurance Plan Variant 54192IN0010012-00 offers Disease Management Program for Diabetes.

    Does CareSource Marketplace Gold Health Insurance Plan, Variant (54192IN0010012-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the CareSource Marketplace Gold Health Insurance Plan Variant 54192IN0010012-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does CareSource Marketplace Gold Health Insurance Plan, Variant (54192IN0010012-00) offer Disease Management Programs for Low back pain?

    Yes, the CareSource Marketplace Gold Health Insurance Plan Variant 54192IN0010012-00 offers Disease Management Program for Low back pain.

    Does CareSource Marketplace Gold Health Insurance Plan, Variant (54192IN0010012-00) offer Disease Management Programs for Pregnancy?

    Yes, the CareSource Marketplace Gold Health Insurance Plan Variant 54192IN0010012-00 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