UHC Bronze Value HSA $6,700 Indiv Ded - 94968KS0090012 Health Insurance Plan

UnitedHealthcare Insurance Company health insurance plan with the Plan ID 94968KS0090012. The plan is called UHC Bronze Value HSA $6,700 Indiv Ded.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 63.23% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 36.77% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 94968KS0090012
Health Insurance Plan Year 2023
State Kansas
Health Insurance Issuer UnitedHealthcare Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 94968KS0090012-00
Provider Network(s) ['KSN001']
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 Kansas 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 - 94968KS0090012-00

Standard On Exchange Plan - 94968KS0090012-01

Open to Indians below 300% FPL - 94968KS0090012-02

Open to Indians above 300% FPL - 94968KS0090012-03

Last Plan Update Date Wed, 25 Jan 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of UHC Bronze Value HSA $6,700 Indiv Ded Health Insurance Plan, 94968KS0090012-00

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

30% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

30% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child

Benefit limitations may apply to individual services.

YES

30% Coinsurance after deductible

100.00%
Chemotherapy
YES

30% Coinsurance after deductible

100.00%
Chiropractic Care
YES

30% Coinsurance after deductible

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

Childbirth/delivery professional services follow inpatient physician/surgeon fees

YES

30% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

YES

No Charge

100.00%
Diabetes Education
YES

30% Coinsurance after deductible

100.00%
Dialysis
YES

30% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

30% Coinsurance after deductible

100.00%
Emergency Room Services
YES

30% Coinsurance after deductible

30% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

30% Coinsurance after deductible

30% Coinsurance after deductible
Eye Glasses for Children

Limit: 3.0 Item(s) per Year

YES

30% Coinsurance after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs

Limit: 34.0 Days per Month

See SBC for non-preferred generic cost shares. Generic medications are available in 102-day supplies through home delivery. Limited to 34 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

YES

$5 Copay after deductible

100.00%
Habilitation Services
YES

30% Coinsurance after deductible

100.00%
Hearing Aids
NO
Home Health Care Services
YES

30% Coinsurance after deductible

100.00%
Hospice Services
YES

30% Coinsurance after deductible

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

30% Coinsurance after deductible

100.00%
Infertility Treatment

Plan covers Diagnosis and treatment of cause of infertility. Benefits are available for covered services such as office visits, laboratory tests, and radiological studies to diagnose the cause of infertility. Benefits are also provided for the necessary treatment of the condition unless the treatment is identified as non-covered (see exclusions). For example, corrective surgical procedures, therapeutic injections, and drug therapy regimens (Pregnyl, Clomid, Clomiphene, Ovidrel, Gonal, Follistim and Cetrotide) are all covered services when medically necessary. Benefits are also available for tests, such as ultrasound, performed to monitor the effectiveness of the fertility drug therapy. Also for any necessary pregnancy testing performed as an integral part of the overall infertility treatment program. Benefits are excluded, however, for any procedures, tests, or other services that are exclusively provided to monitor the effectiveness of non-covered fertilization procedures.

YES

30% Coinsurance after deductible

100.00%
Infusion Therapy
YES

30% Coinsurance after deductible

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

30% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

30% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services

Limit: 18.0 Visit(s) per Year

Limited to 18 Presumptive Drug Tests per year. Limited to 18 Definitive Drug Tests per year.

YES

30% Coinsurance after deductible

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

Benefit limitations may apply to individual services.

YES

30% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

30% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

30% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs

Limit: 34.0 Days per Month

Non-preferred brand medications are available in 102-day supplies through home delivery. Limited to 34 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information

YES

50% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

30% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Coverage is for medically necessary orthodontia only.

YES

50% Coinsurance after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

30% Coinsurance after deductible

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

30% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 90.0 Days per Year

Speech Therapy limited to 1 visit per day, up to 90 days.

YES

30% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

30% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Limit: 34.0 Days per Month

Preferred brand medications are available in 102-day supplies through home delivery. Limited to 34 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

YES

40% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care
YES

No Charge

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

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

$50 Copay after deductible

100.00%
Private-Duty Nursing
YES

30% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

30% Coinsurance after deductible

100.00%
Radiation
YES

30% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

30% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

30% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 90.0 Days per Year

Speech Therapy limited to 1 visit per day, up to 90 days.

YES

30% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children
YES

No Charge

100.00%
Routine Foot Care

Preventive foot care due to conditions associated with metabolic, neurologic, or peripheral vascular disease.

YES

30% Coinsurance after deductible

100.00%
Skilled Nursing Facility
NO
Specialist Visit
YES

30% Coinsurance after deductible

100.00%
Specialty Drugs

Limit: 34.0 Days per Month

Specialty medications are limited to a 34-day supply. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

YES

50% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

30% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

30% Coinsurance after deductible

100.00%
Transplant
YES

30% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

30% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$75 Copay after deductible

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

30% Coinsurance after deductible

100.00%

UHC Bronze-X Value HSA $6,700 Indiv Ded Health Insurance Plan Variant 94968KS0090012-00 Attributes

Plan Attribute Value
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
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID KSF008
Formulary URL URL
HIOS Product ID 94968KS009
Import Date 1/25/2023 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 63.23%
Issuer ID 94968
Issuer Marketplace Marketing Name UnitedHealthcare
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 KSN001
Out of Country Coverage No
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area. The Network Area may include select Network providers located in a neighboring state.
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 94968KS0090012-00
Plan Marketing Name UHC Bronze Value HSA $6,700 Indiv Ded
Plan Type EPO
Plan Variant Marketing Name UHC Bronze-X Value HSA $6,700 Indiv Ded
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $800
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $6,700
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $5,300
SBC Scenario, Having Diabetes, Limit $0
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 KSS001
Source Name SERFF
Plan ID 94968KS0090012
State Code KS
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $13400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $6700 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $6,700
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 $15000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,500
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 Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of UHC Bronze Value HSA $6,700 Indiv Ded Health Insurance Plan, 94968KS0090012

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

Frequently Asked Questions(FAQ) about UHC Bronze Value HSA $6,700 Indiv Ded, 94968KS0090012 Health Insurance Plan, 94968KS0090012

  • Does UHC Bronze Value HSA $6,700 Indiv Ded Health Insurance Plan, 94968KS0090012 support Mail Ordering?

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

  • Does (94968KS0090012) Health Insurance Plan, Variant (94968KS0090012-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (94968KS0090012) Health Insurance Plan, Variant (94968KS0090012-00) have Out of Service Area Coverage?

    Yes. Details: Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area. The Network Area may include select Network providers located in a neighboring state.

 

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