WellFirst Bronze Copay Plus 8650X - 65280IL0010003 Health Insurance Plan

Medica Central Health Plan health insurance plan with the Plan ID 65280IL0010003. The plan is called WellFirst Bronze Copay Plus 8650X.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.68% (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 35.32% 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 65280IL0010003
Health Insurance Plan Year 2022
State Illinois
Health Insurance Issuer Medica Central Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 65280IL0010003-00
Provider Network(s) ['ILN001']
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 Illinois 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 - 65280IL0010003-00

Standard On Exchange Plan - 65280IL0010003-01

Open to Indians below 300% FPL - 65280IL0010003-02

Open to Indians above 300% FPL - 65280IL0010003-03

Last Plan Update Date Wed, 18 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

WellFirst Bronze Copay Plus 8650X Health Insurance Plan Variant 65280IL0010003-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.64682712
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, Diabetes, Pregnancy
EHB Percent of Total Premium 0.9994
First Tier Utilization 100%
Formulary ID ILF006
Formulary URL URL
HIOS Product ID 65280IL001
Import Date 8/18/2021 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? Yes
Issuer ID 65280
Issuer Marketplace Marketing Name WellFirst Health
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 ILN001
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Only
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 65280IL0010003-00
Plan Level Exclusions See policy or plan document for additional excluded services.
Plan Marketing Name WellFirst Bronze Copay Plus 8650X
Plan Type HMO
Plan Variant Marketing Name WellFirst Bronze Copay Plus 8650X
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $8,650
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $600
SBC Scenario, Having Diabetes, Deductible $4,000
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $900
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,700
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID ILS001
Source Name SERFF
Specialist Requiring a Referral All specialty services with the exception of behavioral health and addiction/substance abuse services
Plan ID 65280IL0010003
State Code IL
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 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $17300 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $8650 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $8,650
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 $17300 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8650 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,650
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 No

Copay & Coinsurance of WellFirst Bronze Copay Plus 8650X Health Insurance Plan, 65280IL0010003

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

Frequently Asked Questions(FAQ) about WellFirst Bronze Copay Plus 8650X, 65280IL0010003 Health Insurance Plan, 65280IL0010003

  • Does WellFirst Bronze Copay Plus 8650X Health Insurance Plan, 65280IL0010003 support Mail Ordering?

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

  • Does (65280IL0010003) Health Insurance Plan, Variant (65280IL0010003-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does (65280IL0010003) Health Insurance Plan, Variant (65280IL0010003-00) have Out Of Country Coverage?

    Yes. Details: Emergency Only

    Does (65280IL0010003) Health Insurance Plan, Variant (65280IL0010003-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Only

    Does (65280IL0010003) Health Insurance Plan, Variant (65280IL0010003-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does WellFirst Bronze Copay Plus 8650X Health Insurance Plan, Variant (65280IL0010003-00) offer Disease Management Programs for Asthma?

    Yes, the WellFirst Bronze Copay Plus 8650X Health Insurance Plan Variant 65280IL0010003-00 offers Disease Management Program for Asthma.

    Does WellFirst Bronze Copay Plus 8650X Health Insurance Plan, Variant (65280IL0010003-00) offer Disease Management Programs for Heart disease?

    Yes, the WellFirst Bronze Copay Plus 8650X Health Insurance Plan Variant 65280IL0010003-00 offers Disease Management Program for Heart disease.

    Does WellFirst Bronze Copay Plus 8650X Health Insurance Plan, Variant (65280IL0010003-00) offer Disease Management Programs for Diabetes?

    Yes, the WellFirst Bronze Copay Plus 8650X Health Insurance Plan Variant 65280IL0010003-00 offers Disease Management Program for Diabetes.

    Does WellFirst Bronze Copay Plus 8650X Health Insurance Plan, Variant (65280IL0010003-00) offer Disease Management Programs for Pregnancy?

    Yes, the WellFirst Bronze Copay Plus 8650X Health Insurance Plan Variant 65280IL0010003-00 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