SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam - 52664OH1530007 Health Insurance Plan

Summa Insurance Company, Inc. health insurance plan with the Plan ID 52664OH1530007. The plan is called SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam .

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.17% (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 35.83% 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 52664OH1530007
Health Insurance Plan Year 2023
State Ohio
Health Insurance Issuer Summa Insurance Company, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 52664OH1530007-00
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 - 52664OH1530007-00

Standard On Exchange Plan - 52664OH1530007-01

Open to Indians below 300% FPL - 52664OH1530007-02

Open to Indians above 300% FPL - 52664OH1530007-03

Last Plan Update Date Thu, 15 Sep 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, 52664OH1530007-00

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

Limit: 3000.0 Dollars per Episode

Exclusions: Damage to teeth due to chewing or biting is not deemed an accidental injury and is not covered.

Quantitative Limit represents established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply. Coverage for dental services resulting from an accidental injury when treatment is performed within 12 months after the injury. The benefit limit will not apply to outpatient facility charges, anesthesia billed by a provider other than the physician performing the service, or to covered services required by law; coverage includes oral examinations, x-rays, tests and laboratory examinations, restorations, prosthetic services, oral surgery, mandibular/maxillary reconstruction, anesthesia and include facility charges for outpatient services for the removal of teeth or for other dental processes if the patient?s medical condition or the dental procedure requires a hospital setting to ensure the safety of the patient.

YES

0.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

0.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult

Exclusions: Adult dental treatment, regardless of origin or cause, is excluded except as specified in the base-benchmark plan when related to accidental injury (limits apply), or for certain services related to transplant preparation, initiation of immunosuppresives, or direct treatment of acute traumatic injury, cancer or cleft palate. Excluded dental treatment includes but is not limited to: Preventive care, diagnosis, treatment of or related to the teeth, jawbones (except that TMJ is a Covered Service) or gums.

See Accidental Dental benefit for additional information.

NO
Basic Dental Care - Child

Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan.

NO
Chemotherapy
YES

0.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 12.0 Visit(s) per Benefit Period

Exclusions: Manipulation therapy services rendered in the home as part of Home Care Services.

Benefit limit applies for Osteopathic/Chiropractic Manipulation Therapy.

YES

0.00% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Exclusions: Any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple).

Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Prenatal Care.

YES

0.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 1.0 Exam(s) per 6 Months

Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan.

NO
Diabetes Education

Diabetes Self-Management Training for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition.

YES

0.00% Coinsurance after deductible

100.00%
Dialysis

Benefits include supportive use of an artificial kidney machine.

YES

0.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Exclusions: Items for personal hygiene, environmental control or convenience; exercise equipment; repair and replacement due to misuse, malicious breakage or gross neglect, loss or theft; medical and surgical supplies (usually stocked in the home for general use like- band aids, thermometers, and petroleum jelly); arch supports; doughnut cushions; vitamins; medi-jectors; air conditioners; hot packs; ice bags/ cold pack pump; raised toilet seats; rental of equipment where facility is expected to provide such equipment; trans lift chairs; treadmill exerciser; tub chair; dentures, dental appliances; non-rigid appliances; artificial heart implants; wigs (except following cancer treatment); penile prosthesis in men suffering impotency; orthopedic shoes (except therapeutic shoes for diabetics); foot support devices and corrective shoes, unless they are an integral part of a leg brace; standard elastic stockings and other supplies not specially made and fitted (except as specified under medical supplies); garter belts or similar devices.

Covered services include durable medical equipment, medical devices and supplies, prosthetics and appliances, including cochlear implants and eyeglasses/contact lenses (for cataract surgery or injury), and medical/surgical supplies and equipment that serve only a medical purpose for the management of disease. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period; (as required by the Women?s Health and Cancer Rights Act); Left Ventricular Artificial Devices (LVAD) covered only as bridge to heart transplant.

YES

0.00% Coinsurance after deductible

100.00%
Emergency Room Services

Exclusions: For care received in an emergency room, which is not, Emergency Care, including, but not limited to suture removal in an emergency room.

YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Exclusions: Non Covered Services for Ambulance include but are not limited to, trips to: a Physician's office or clinic; a morgue or funeral home; ambulance usage when another type of transportation can be used without endangering the member's health or any ambulance usage for the convenience of the member, family, or physician; transport by ambulette. Out-of-network ambulance services are excluded except in an emergency or with prior authorization.

Ambulance Services are transportation by a vehicle (including ground, water, fixed wing and rotary wing air transportation) designed, equipped and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals: from home, scene of accident or medical emergency to a hospital; between hospitals; between a hospital and skilled nursing facility; or from a hospital or skilled nursing facility to home; ambulance trips must be made to the closest facility that can give covered services appropriate for the member's condition.

YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits.

YES

No Charge

100.00%
Gender Affirming Care

Exclusions: Procedures performed for the sole purpose of improving or altering appearance or self-esteem related to one's appearance are considered cosmetic in nature, not medically necessary and not covered services.

Transexual surgery and related services including pre and post-surgery diagnostics, treatments, and drug therapy must be prior authorized and will be covered based upon medical necessity. Cost shares are based on where the transsexual surgery and related services are provided.

YES

0.00% Coinsurance after deductible

100.00%
Generic Drugs

Exclusions: Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications.

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.

YES

0.00% Coinsurance after deductible

100.00%
Habilitation Services

Limits may apply to some services; includes benefits for health care services and devices that help a person keep, learn or improve skills and functioning for daily living, including treatment of Autism Spectrum Disorders to children (0 - 21), which at a minimum shall include: (1) Out-Patient Physical Rehabilitation Services including (a) Speech and Language therapy and/or Occupational therapy, 20 visits per year of each service; and (b) Clinical Therapeutic Intervention, which include but are not limited to Applied Behavioral Analysis, 20 hours per week; and (2) Mental/Behavioral Health Outpatient Services to provide consultation, assessment, development and oversight of treatment plans.

YES

0.00% Coinsurance after deductible

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 100.0 Visit(s) per Benefit Period

Exclusions: Food, housing, homemaker services and home delivered meals; Home or Outpatient hemodialysis services (these are covered under Therapy Services); Physician charges; Helpful environmental materials (hand rails, ramps, telephones, air conditioners, and similar services, appliances and devices); Services provided by registered nurses and other health workers who are not acting as employees or under approved arrangements with a contracting Home Health Care Provider; Services provided by a member of the patient's immediate family; Services provided by volunteer ambulance associations for which patient is not obligated to pay; visiting teachers, vocational guidance and other counselors, and services related to outside occupational and social activities; Manipulation Therapy services rendered in the home.

When therapy services are provided in the home (including physical, speech, and occupational therapy) as part of home health care services, they are not subject to separate visit limits for therapy services. The 100 visit/year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting.

YES

0.00% Coinsurance after deductible

100.00%
Hospice Services

To be eligible for Hospice benefits, the patient must have a life expectancy of six months or less, as confirmed by the attending Physician.

YES

0.00% Coinsurance after deductible

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

0.00% Coinsurance after deductible

100.00%
Infertility Treatment

Exclusions: Infertility treatment is excluded except as required under state law for HMO plans

Infertility and voluntary family planning services are required benefits under state law for HMO plans only per ORC section 1751.01 (A)(1)(h), and must be provided in accordance with Ohio Department of Insurance Bulletin No. 2009-07.

YES

0.00% Coinsurance after deductible

100.00%
Infusion Therapy

Home IV therapy includes but is not limited to: injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy.

YES

0.00% Coinsurance after deductible

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

Exclusions: Surgical treatment of dental conditions, reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dysfunction; surgeries or services for sexual transformation; surgical treatment of flat feet, subluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremity; treatment of telangiectatic dermal veins; cosmetic surgery; bariatric surgery.

There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services; and ancillary (related) services. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services.

YES

0.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services

Exclusions: Surgical treatment of dental conditions, reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dysfunction; surgeries or services for sexual transformation; surgical treatment of flat feet, subluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremity; treatment of telangiectatic dermal veins; cosmetic surgery; bariatric surgery.

There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient medical care visits limited to one visit per day by any one physician.

YES

0.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

0.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult

Exclusions: Adult dental treatment, regardless of origin or cause, is excluded except as specified in the base-benchmark plan when related to accidental injury (limits apply), or for certain services related to transplant preparation, initiation of immunosuppresives, or direct treatment of acute traumatic injury, cancer or cleft palate. Excluded dental treatment includes but is not limited to: Preventive care, diagnosis, treatment of or related to the teeth, jawbones (except that TMJ is a Covered Service) or gums.

See Accidental Dental benefit for additional information.

NO
Major Dental Care - Child

Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan.

NO
Mental/Behavioral Health Inpatient Services

Exclusions: Custodial or domiciliary Care. Room and board charges unless the treatment provided meets medical necessity criteria for Inpatient admission for patient's condition. Supervised living or halfway houses, services or care provided or billed by a hotel, health resort, convalescent/rest/nursing home, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps.

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

YES

0.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Exclusions: Custodial or domiciliary Care. Supervised living or halfway houses, services or care provided or billed by a hotel, health resort, convalescent/rest/nursing home, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps.

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

YES

0.00% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs

Exclusions: Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.

YES

0.00% Coinsurance after deductible

100.00%
Nutritional Counseling

Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services (includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors).

YES

No Charge

100.00%
Orthodontia - Adult

Exclusions: Adult dental treatment, regardless of origin or cause, is excluded except as specified in the base-benchmark plan when related to accidental injury (limits apply), or for certain services related to transplant preparation, initiation of immunosuppresives, or direct treatment of acute traumatic injury, cancer or cleft palate. Excluded dental treatment includes but is not limited to: Preventive care, diagnosis, treatment of or related to the teeth, jawbones (except that TMJ is a Covered Service) or gums.

See Accidental Dental benefit for additional information.

NO
Orthodontia - Child

Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan.

NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

0.00% Coinsurance after deductible

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

Exclusions: Surgical treatment of dental conditions, reversal of voluntary sterilzation; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dsfunction; surgeries or services for sexual transformation,; surgical treatment of flat feet, sugbluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremelty; tretment of telangtiectatic dermal veins; cosmetic surgery; bariatric surgery.

See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document; benefits for facility charges for Outpatient Services are payable for the removal of teeth or for other dental processes only if the patient?s medical condition or the dental procedure requires a Hospital setting to ensure the safety of the patient

YES

0.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 116.0 Visit(s) per Benefit Period

Exclusions: Non-Covered Services include: Physical Therapy - maintenance therapy, repetitive exercise, range of motion and passive exercises that are not related to restoration of a specific loss of function; general exercise programs; diathermy, ultrasound and heat treatments for pulmonary conditions; diapulse; work hardening. Occupational Therapy - diversional, recreational, vocational therapies and supplies; general exercises to promote overall fitness and flexibility; therapy to improve motivation; suction therapy for newborns (feeding machines); soft tissue mobilization (visceral manipulation or visceral soft tissue manipulation), augmented soft tissue mobilization, myofascial; adaptions to the home. Cardiac Rehabilitation - home programs, ongoing conditioning and maintenance. Pulmonary Rehabilitation - services provided in the acute inpatient rehabilitation setting

Therapy Services rendered in the home as part of Home Care Services will be subject to the Home Care Services visit limits; outpatient rehabilitation services visit limits will not apply. If different types of Therapy Services are performed during one Physician Home Visit, Office Service, or Outpatient Service, then each different type of Therapy Service performed will be considered a separate Therapy Visit. Each Therapy Visit will count against the applicable maximum visits per Benefit Period listed below: Physical, Occupational and Speech Therapy limited to 20 visits each. Cardiac Rehabilitation limited to 36 visits. Pulmonary Rehabilitation limited to 20 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply. Benefit also includes Physical Medicine and Rehabilitation Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services.

YES

0.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services

Exclusions: Surgical treatment of dental conditions, reversal of voluntary sterilzation; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dsfunction; surgeries or services for sexual transformation,; surgical treatment of flat feet, sugbluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremelty; tretment of telangtiectatic dermal veins; cosmetic surgery; bariatric surgery.

See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document.

YES

0.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Exclusions: Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications.

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.

YES

0.00% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care

Exclusions: Any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple).

Includes post-delivery follow-up care performed, by a physician or nurse, within 72 hours of discharge, through home health care visits or, at patient?s discretion, in a medical setting. This coverage includes, but is not limited to parent education; assistance and training in breast or bottle feeding; and routine maternal or neonatal tests and screening (including collection of sample for hereditary and metabolic newborn screening).

YES

0.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization

Services with an 'A' or 'B' rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration including: women?s contraceptives, sterilization procedures, and counseling; breastfeeding support, supplies, and counseling (benefits for breast pumps are limited to one pump per benefit period); and gestational diabetes screening; routine screening mammograms; routine cytologic screening; child health supervision services from birth to age 9.

YES

No Charge

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

0.00% Coinsurance after deductible

100.00%
Private-Duty Nursing

Limit: 90.0 Visit(s) per Benefit Period

Private Duty Nursing Services are Covered Services only when provided through the Home Care Services benefit; Quantitative Limit has been determined as 90 - 110 visits per year and represents the number of visits to meet the established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply.

YES

0.00% Coinsurance after deductible

100.00%
Prosthetic Devices

Exclusions: Dentures, replacing teeth or structures directly supporting teeth; Dental appliances; Such non-rigid appliances as elastic stockings, garter belts, arch supports and corsets; Artificial heart implants; Wigs (except following cancer treatment); Penile prosthesis in men suffering impotency resulting from disease or injury.

Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that 1) Replace all or part of a missing body part and its adjoining tissues; or 2) Replace all or part of the function of a permanently useless or malfunctioning body part.

YES

0.00% Coinsurance after deductible

100.00%
Radiation
YES

0.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Exclusions: Reconstructive services needed as a result of an earlier treatment are covered only if the first treatment would have been a covered service under the plan; coverage for reconstructive services does not apply to orthognathic 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

0.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Benefit Period

Exclusions: Non-Covered Services include:Physical Therapy - maintenance therapy, repetitive exercise, range of motion and passive exercises that are not relatedto restoration of a specific loss of function; general exercise programs; diathermy, ultrasound and heat treatments for pulmonary conditions; diapulse;work hardening. Occupational Therapy - diversional, recreational, vocational therapies and supplies; general exercisesto promote overall fitness and flexibility; therapy to improve motivation; suction therapy for newborns (feeding machines); soft tissue mobilization (visceral manipulation or visceral soft tissue manipulation), augmented soft tissue mobilization, myofascial; adaptions to the home.

Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period.

YES

0.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Benefit Period

YES

0.00% Coinsurance after deductible

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

Limit: 1.0 Visit(s) per Year

Routine refraction per year; eye exams for medical conditions of the eye.

YES

0.00% Coinsurance after deductible

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits.

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 90.0 Days per Benefit Period

Exclusions: Custodial or domiciliary care.

Benefits include Items and services provided as an inpatient in a skilled nursing bed of skilled nursing facility or hospital, including room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies.

YES

0.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

0.00% Coinsurance after deductible

100.00%
Specialty Drugs

Exclusions: Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications.

Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state's EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.

YES

0.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Exclusions: Custodial or domiciliary Care. Room and board charges unless the treatment provided meets medical necessity criteria for Inpatient admission for patient's condition. Supervised living or halfway houses, services or care provided or billed by a hotel, health resort, convalescent/rest/nursing home, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps.

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

YES

0.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Exclusions: Services or care provided or billed by a halfway house, hotel, health resort, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps.

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

YES

0.00% Coinsurance after deductible

100.00%
Transplant

Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined). Transplant benefits apply to any medically necessary human organ and stem cell/bone marrow transplants (except cornea and kidney transplants) and transfusions including necessary acquisition procedures, harvest and storage, necessary preparatory myeloablative therapy, and initial evaluation/testing to determine eligibility as a transplant candidate.

YES

0.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Benefits provided for temporomandibular (joint connecting the lower jaw to the temporal bone at the side of the head) and craniomandibular (head and neck muscle) disorders.

YES

0.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

0.00% Coinsurance after deductible

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

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

0.00% Coinsurance after deductible

100.00%

SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530007-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.641674935
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 Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 0.9968
First Tier Utilization 100%
Formulary ID OHF001
Formulary URL URL
HIOS Product ID 52664OH153
Import Date 9/15/2022 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 52664
Issuer Marketplace Marketing Name SummaCare
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 Coverage
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency and Urgent Care Coverage
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 52664OH1530007-00
Plan Marketing Name SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam
Plan Type HMO
Plan Variant Marketing Name SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $7,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $2,300
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 OHS001
Source Name SERFF
Plan ID 52664OH1530007
State Code OH
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $14000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $7000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $7,000
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $14000 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $7000 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $7,000
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 $14000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,000
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 $14000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,000
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 SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, 52664OH1530007

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

Frequently Asked Questions(FAQ) about SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam , 52664OH1530007 Health Insurance Plan, 52664OH1530007

  • Does SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, 52664OH1530007 support Mail Ordering?

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

  • Does (52664OH1530007) Health Insurance Plan, Variant (52664OH1530007-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs

    Does (52664OH1530007) Health Insurance Plan, Variant (52664OH1530007-00) have Out Of Country Coverage?

    Yes. Details: Emergency Coverage

    Does (52664OH1530007) Health Insurance Plan, Variant (52664OH1530007-00) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Care Coverage

    Does (52664OH1530007) Health Insurance Plan, Variant (52664OH1530007-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs

    Does SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, Variant (52664OH1530007-00) offer Disease Management Programs for Asthma?

    Yes, the SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530007-00 offers Disease Management Program for Asthma.

    Does SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, Variant (52664OH1530007-00) offer Disease Management Programs for Heart disease?

    Yes, the SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530007-00 offers Disease Management Program for Heart disease.

    Does SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, Variant (52664OH1530007-00) offer Disease Management Programs for Depression?

    Yes, the SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530007-00 offers Disease Management Program for Depression.

    Does SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, Variant (52664OH1530007-00) offer Disease Management Programs for Diabetes?

    Yes, the SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530007-00 offers Disease Management Program for Diabetes.

    Does SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, Variant (52664OH1530007-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530007-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, Variant (52664OH1530007-00) offer Disease Management Programs for Pregnancy?

    Yes, the SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530007-00 offers Disease Management Program for Pregnancy.

    Does SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, Variant (52664OH1530007-00) offer Disease Management Programs for Weight loss programs?

    Yes, the SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530007-00 offers Disease Management Program for Weight loss programs.

 

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