SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam - 52664OH1530033 Health Insurance Plan

Summa Insurance Company, Inc. health insurance plan with the Plan ID 52664OH1530033. The plan is called SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 61.14% (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 38.86% 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 52664OH1530033
Health Insurance Plan Year 2022
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 52664OH1530033-00
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 - 52664OH1530033-00

Standard On Exchange Plan - 52664OH1530033-01

Open to Indians below 300% FPL - 52664OH1530033-02

Open to Indians above 300% FPL - 52664OH1530033-03

Last Plan Update Date Tue, 17 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530033-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.611404656
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, Pain Management, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 0.9968
First Tier Utilization 100%
Formulary ID OHF007
Formulary URL URL
HIOS Product ID 52664OH153
Import Date 8/17/2021 20:00
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 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 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 1/1/2022
Plan ID (Standard Component ID with Variant) 52664OH1530033-00
Plan Marketing Name SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam
Plan Type HMO
Plan Variant Marketing Name SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,300
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $8,000
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 52664OH1530033
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 $16000 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $8000 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $8,000
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 $16000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $8000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $8,000
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 SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, 52664OH1530033

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

Frequently Asked Questions(FAQ) about SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam, 52664OH1530033 Health Insurance Plan, 52664OH1530033

  • Does SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, 52664OH1530033 support Mail Ordering?

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

  • Does (52664OH1530033) Health Insurance Plan, Variant (52664OH1530033-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Weight Loss Programs

    Does (52664OH1530033) Health Insurance Plan, Variant (52664OH1530033-00) have Out Of Country Coverage?

    Yes. Details: Emergency Coverage

    Does (52664OH1530033) Health Insurance Plan, Variant (52664OH1530033-00) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Care Coverage

    Does (52664OH1530033) Health Insurance Plan, Variant (52664OH1530033-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Weight Loss Programs

    Does SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, Variant (52664OH1530033-00) offer Disease Management Programs for Asthma?

    Yes, the SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530033-00 offers Disease Management Program for Asthma.

    Does SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, Variant (52664OH1530033-00) offer Disease Management Programs for Heart disease?

    Yes, the SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530033-00 offers Disease Management Program for Heart disease.

    Does SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, Variant (52664OH1530033-00) offer Disease Management Programs for Depression?

    Yes, the SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530033-00 offers Disease Management Program for Depression.

    Does SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, Variant (52664OH1530033-00) offer Disease Management Programs for Diabetes?

    Yes, the SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530033-00 offers Disease Management Program for Diabetes.

    Does SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, Variant (52664OH1530033-00) offer Disease Management Programs for Pregnancy?

    Yes, the SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530033-00 offers Disease Management Program for Pregnancy.

    Does SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan, Variant (52664OH1530033-00) offer Disease Management Programs for Weight loss programs?

    Yes, the SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam Health Insurance Plan Variant 52664OH1530033-00 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