CareSource Marketplace Gold Dental, Vision, & Fitness - 54192IN0020012 Health Insurance Plan
CareSource Indiana, Inc. health insurance plan with the Plan ID 54192IN0020012. The plan is called CareSource Marketplace Gold Dental, Vision, & Fitness.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.00% (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 22.00% 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 | 54192IN0020012 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Indiana | ||||||||||||||||||
| Health Insurance Issuer | CareSource Indiana, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 54192IN0020012-00 | ||||||||||||||||||
| Provider Network(s) | ['INN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 54192IN0020012-00 Standard On Exchange Plan - 54192IN0020012-01 |
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| Last Plan Update Date | Fri, 18 Nov 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, 54192IN0020012-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Limit: 3000.0 Dollars per Episode Injury as a result of chewing or biting is not considered an accidental injury. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits. |
YES | 15.00% |
100.00% |
| Basic Dental Care - Child
See plan documents for details on benefit limits |
YES | 15.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Year |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Exam(s) per Year |
YES | $0.00 |
100.00% |
| Diabetes Education
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Ambulance transports must be made to the closest local facility that can provide you with covered services appropriate for your medical condition. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Limited to one pair of glasses or contact lenses per benefit year. |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
|
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year Physical Therapy, Occupational Therapy, and Speech Therapy limited to 20 visits each per benefit period. |
YES | $30.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period A visit equals at least 4 hours. Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance 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 | 40.00% |
100.00% |
| Major Dental Care - Child
See plan documents for details on benefit limits |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $60.00 |
100.00% |
| Nutritional Counseling
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Limited to Medically Necessary Orthodontia. See plan documents for details on benefit limits. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Physical Therapy, Occupational Therapy, and Speech Therapy limited to 20 visits each per benefit period.? Cardiac Rehabilitation limited to 36 visits. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $60.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
| Private-Duty Nursing
Limit: 100.0 Visit(s) per Year A visit equals 8 hours. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| 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 | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year Physical Therapy and Occupational Therapy limited to 20 visits each per benefit period. |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year |
YES | $30.00 |
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: 2.0 Visit(s) per Year |
YES | $50.00 |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 90.0 Days per Year |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
|
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
100.00% |
| Transplant
Quantitative limit units apply, see Summary of Benefits and Coverage. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $45.00 |
$45.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan Variant 54192IN0020012-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.780017779 |
| 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 Gold 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 | 0.986193294 |
| First Tier Utilization | 100% |
| Formulary ID | INF003 |
| Formulary URL | URL |
| HIOS Product ID | 54192IN002 |
| Import Date | 11/18/2022 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 | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 54192IN0020012-00 |
| Plan Marketing Name | CareSource Marketplace Gold Dental, Vision, & Fitness |
| Plan Type | HMO |
| Plan Variant Marketing Name | CareSource Marketplace Gold Dental, Vision, & Fitness |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,000 |
| SBC Scenario, Having a Baby, Copayment | $70 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $500 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| 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 | $300 |
| 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 | 54192IN0020012 |
| State Code | IN |
| 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 | $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 | 25.00% |
| 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 | $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 Gold Dental, Vision, & Fitness Health Insurance Plan, 54192IN0020012
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about CareSource Marketplace Gold Dental, Vision, & Fitness, 54192IN0020012 Health Insurance Plan, 54192IN0020012
-
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, 54192IN0020012 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (54192IN0020012) Health Insurance Plan, Variant (54192IN0020012-00) offer Disease Management Programs?
Does (54192IN0020012) Health Insurance Plan, Variant (54192IN0020012-00) have Out Of Country Coverage?
Does (54192IN0020012) Health Insurance Plan, Variant (54192IN0020012-00) have Out of Service Area Coverage?
Does (54192IN0020012) Health Insurance Plan, Variant (54192IN0020012-00) offer Disease Management Programs?
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, Variant (54192IN0020012-00) offer Disease Management Programs for Asthma?
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, Variant (54192IN0020012-00) offer Disease Management Programs for Heart disease?
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, Variant (54192IN0020012-00) offer Disease Management Programs for Depression?
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, Variant (54192IN0020012-00) offer Disease Management Programs for Diabetes?
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, Variant (54192IN0020012-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, Variant (54192IN0020012-00) offer Disease Management Programs for Low back pain?
Does CareSource Marketplace Gold Dental, Vision, & Fitness Health Insurance Plan, Variant (54192IN0020012-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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