CareSource Marketplace Gold Dental, Vision, & Fitness
77552OH0020202
Gold
HMO
CareSource Marketplace Gold Dental, Vision, & Fitness is a Gold HMO plan by CareSource.
IMPORTANT: You are viewing the 2023 version of CareSource Marketplace Gold Dental, Vision, & Fitness 77552OH0020202. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
CareSource Marketplace Gold Dental, Vision, & Fitness is offered in the following counties.
Plan Overview
This is a plan overview for 2023 version of CareSource Marketplace Gold Dental, Vision, & Fitness 77552OH0020202.
| Insurer: | CareSource |
| Network Type: | HMO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 77552OH0020202 |
Cost-Sharing Overview
CareSource Marketplace Gold Dental, Vision, & Fitness offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for CareSource Marketplace Gold Dental, Vision, & Fitness includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8,700.00 | $8700 per person | $17400 per group |
| Deductible: | $2,000.00 | $2000 per person | $4000 per group |
| Coinsurance: | 25.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for CareSource Marketplace Gold Dental, Vision, & Fitness will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | $2,000.00 (in-and-out of network) | $2000 per person (in-and-out of network) | $4000 per group (in-and-out of network) |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $2,000.00 |
| Copayment: | $10.00 |
| Coinsurance: | $2,600.00 |
| Limit: | $60.00 |
| Deductible: | $2,000.00 |
| Copayment: | $500.00 |
| Coinsurance: | $500.00 |
| Limit: | $20.00 |
| Deductible: | $2,000.00 |
| Copayment: | $300.00 |
| Coinsurance: | $20.00 |
| Limit: | $0.00 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for CareSource Marketplace Gold Dental, Vision, & Fitness?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
CareSource Marketplace Gold Dental, Vision, & Fitness offers the following features and referral requirements.
| Wellness Program: | Yes |
| Disease Program: | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| Notice Pregnancy: | Yes |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what CareSource Marketplace Gold Dental, Vision, & Fitness covers when you are out of the service area or out of the country.
| 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 |
| National Network: | No |
Additional Benefits and Cost-Sharing
CareSource Marketplace Gold Dental, Vision, & Fitness includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | $30.00 | 100.00% | |
| Specialist Visit Covered | $60.00 | 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $30.00 | 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | 25.00% Coinsurance after deductible | 100.00% | See 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 |
| Outpatient Surgery Physician/Surgical Services Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Hospice Services Covered | 25.00% Coinsurance after deductible | 100.00% | To be eligible for Hospice benefits, the patient must have a life expectancy of six months or less, as confirmed by the attending Physician. |
| Routine Dental Services (Adult) Covered | $0.00 | 100.00% | 2 Visit(s) per Year |
| Infertility Treatment Covered | 25.00% Coinsurance after deductible | 100.00% | The diagnosis and treatment of underlying medical causes of infertility are generally covered, however infertility treatments, such as artificial insemination/invitro fertilization, are not covered |
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | 25.00% Coinsurance after deductible | 100.00% | 100 Visit(s) per Year Private Duty Nursing Services are Covered Services only when provided through the Home Care Services benefit; A visit equals 8 hours. |
| Routine Eye Exam (Adult) Covered | $50.00 | 100.00% | 1 Exam(s) per Year |
| Urgent Care Centers or Facilities Covered | $45.00 | $45.00 | |
| Home Health Care Services Covered | 25.00% Coinsurance after deductible | 100.00% | 100 Visit(s) per Year 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. A visit equals at least 4 hours. |
| Emergency Room Services Covered | 25.00% Coinsurance after deductible | 25.00% Coinsurance after deductible | Emergency room copay or coinsurance is waived if you are admitted to the hospital directly from the Emergency Department. |
| Emergency Transportation/Ambulance Covered | 25.00% Coinsurance after deductible | 25.00% Coinsurance after deductible | Ambulance transports must be made to the closest local facility that can provide you with covered services appropriate for your medical condition. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | 25.00% Coinsurance after deductible | 100.00% | There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include |
| Inpatient Physician and Surgical Services Covered | 25.00% Coinsurance after deductible | 100.00% | 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. |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | 25.00% Coinsurance after deductible | 100.00% | 90 Days per Year 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. |
| Prenatal and Postnatal Care Covered | $60.00 | 100.00% | 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). |
| Delivery and All Inpatient Services for Maternity Care Covered | 25.00% Coinsurance after deductible | 100.00% | 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. |
| Mental/Behavioral Health Outpatient Services Covered | $30.00 | 100.00% | |
| Mental/Behavioral Health Inpatient Services Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | $30.00 | 100.00% | |
| Substance Abuse Disorder Inpatient Services Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Generic Drugs Covered | $15.00 | 100.00% | |
| Preferred Brand Drugs Covered | $30.00 | 100.00% | |
| Non-Preferred Brand Drugs Covered | $60.00 | 100.00% | |
| Specialty Drugs Covered | $250.00 | 100.00% | |
| Outpatient Rehabilitation Services Covered | 25.00% Coinsurance after deductible | 100.00% | 60 Visit(s) per Year 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. |
| Habilitation Services Covered | $30.00 | 100.00% | 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. Includes Physical, Occupational and Speech Therapy limited to 20 visits each. Autism Spectrum Disorder Services for children (0 – 21) includes: (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) Adaptive Behavior Treatment, which include but are not limited to Applied Behavioral Analysis and (2) Mental/Behavioral Health Outpatient Services to provide consultation, assessment, development and oversight of treatment plans. |
| Chiropractic Care Covered | 25.00% Coinsurance after deductible | 100.00% | 12 Visit(s) per Year Benefit limit applies for Osteopathic/Chiropractic Manipulation Therapy. |
| Durable Medical Equipment Covered | 25.00% Coinsurance after deductible | 100.00% | 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. |
| Hearing Aids Not Covered | |||
| Imaging (CT/PET Scans, MRIs) Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Preventive Care/Screening/Immunization Covered | 0.00% | 100.00% | 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. |
| Routine Foot Care Not Covered | |||
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | $0.00 0.00% | 100.00% | 1 Exam(s) per Year |
| Eye Glasses for Children Covered | $0.00 0.00% | 100.00% | 1 Item(s) per Year Limited to one pair of glasses or a 12-month supply of contact lenses per benefit year. |
| Dental Check-Up for Children Covered | $0.00 | 100.00% | 2 Visit(s) per Year See plan documents for details on benefit limits |
| Rehabilitative Speech Therapy Covered | $30.00 | 100.00% | 20 Visit(s) per Year |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $30.00 | 100.00% | 20 Visit(s) per Year Quantitative limit units apply, see Summary of Benefits and Coverage. |
| Well Baby Visits and Care Covered | 0.00% | 100.00% | |
| Laboratory Outpatient and Professional Services Covered | 25.00% Coinsurance after deductible | 100.00% | |
| X-rays and Diagnostic Imaging Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Basic Dental Care – Child Covered | 15.00% Coinsurance after deductible | 100.00% | See plan documents for details on benefit limits |
| Orthodontia – Child Covered | 40.00% Coinsurance after deductible | 100.00% | Limited to Medically Necessary Orthodontia. See plan documents for details on benefit limits. |
| Major Dental Care – Child Covered | 40.00% Coinsurance after deductible | 100.00% | See plan documents for details on benefit limits |
| Basic Dental Care – Adult Covered | 15.00% | 100.00% | |
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Covered | 40.00% | 100.00% | |
| Abortion for Which Public Funding is Prohibited Not Covered | Coverage for nontherapeutic abortion is prohibited for Qualified Health Plans per Ohio Revised Code ? 3901.87. | ||
| Transplant Covered | 25.00% Coinsurance after deductible | 100.00% | 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. |
| Accidental Dental Covered | 25.00% Coinsurance after deductible | 100.00% | 3000 Dollars per Episode |
| Dialysis Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Allergy Testing Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Chemotherapy Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Radiation Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Diabetes Education Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Prosthetic Devices Covered | 25.00% Coinsurance after deductible | 100.00% | 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. |
| Infusion Therapy Covered | 25.00% Coinsurance after deductible | 100.00% | 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. |
| Treatment for Temporomandibular Joint Disorders Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Nutritional Counseling Covered | 25.00% Coinsurance after deductible | 100.00% | 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). |
| Reconstructive Surgery Covered | 25.00% Coinsurance after deductible | 100.00% | 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. |
| Gender Affirming Care Covered | 25.00% Coinsurance after deductible | 100.00% | Surgery determined to be Medically Necessary is Covered |
Free Preventive Services
There is no copayment or coinsurance for any of the following CareSource Marketplace Gold Dental, Vision, & Fitness preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for CareSource Marketplace Gold Dental, Vision, & Fitness including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
Ready to sign up for CareSource Marketplace Gold Dental, Vision, & Fitness?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904