CareSource Marketplace Standard Silver

63876IA0010005
Silver
HMO

CareSource Marketplace Standard Silver is a Silver HMO plan by CareSource Iowa Co..

IMPORTANT: You are viewing the 2023 version of CareSource Marketplace Standard Silver 63876IA0010005. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

CareSource Marketplace Standard Silver is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of CareSource Marketplace Standard Silver 63876IA0010005.
Insurer: CareSource Iowa Co.
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 63876IA0010005

Cost-Sharing Overview

CareSource Marketplace Standard Silver offers the following cost-sharing.

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 Standard Silver?

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 Standard Silver 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 Standard Silver 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 Standard Silver 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
$40.00 100.00%
Specialist Visit
Covered
$80.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
40.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
40.00% Coinsurance after deductible 100.00% Hospice respite care has a quantity limit of (15) fifteen inpatient and (15) fifteen outpatient days per lifetime. Hospice respite care must be used in increments of not more than (5) five days at a time.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
40.00% Coinsurance after deductible 100.00%
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
40.00% Coinsurance after deductible 100.00% Plan refers to home skilled nursing as private duty nursing. Home skilled nursing is intended to provide a safe transition from other levels of care when medically necessary, to provide teaching to caregivers for ongoing care, or to provide short-term treatments that can be safely administered in the home setting.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$60.00 $60.00
Home Health Care Services
Covered
40.00% Coinsurance after deductible 100.00%
Emergency Room Services
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
40.00% Coinsurance after deductible 40.00% 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
40.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
40.00% Coinsurance after deductible 100.00% Surgery must be medically necessary. Not all procedures classified as weight reduction surgery are covered.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
40.00% Coinsurance after deductible 100.00%
Prenatal and Postnatal Care
Covered
$80.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
40.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$40.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$40.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$20.00 100.00%
Preferred Brand Drugs
Covered
$40.00 100.00%
Non-Preferred Brand Drugs
Covered
$80.00 Copay after deductible 100.00%
Specialty Drugs
Covered
$350.00 Copay after deductible 100.00%
Outpatient Rehabilitation Services
Covered
40.00% Coinsurance after deductible 100.00%
Habilitation Services
Covered
$40.00 100.00% Treatment for Autism with speech therapy, occupational therapy, or physical therapy is covered.
Chiropractic Care
Covered
40.00% Coinsurance after deductible 100.00%
Durable Medical Equipment
Covered
40.00% Coinsurance after deductible 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
40.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
0.00% 100.00%
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 Benefit Period
Eye Glasses for Children
Covered
$0.00 0.00% 100.00%1 Item(s) per Benefit Period Limited to one pair of glasses or contact lenses per benefit year. If medically necessary a replacement pair of glasses is allowed.
Dental Check-Up for Children
Covered
$0.00 100.00%2 Visit(s) per Year
Rehabilitative Speech Therapy
Covered
$40.00 100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 100.00%
Well Baby Visits and Care
Covered
0.00% 100.00% Covered for child through age 7.
Laboratory Outpatient and Professional Services
Covered
40.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
40.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Covered
25.00% Coinsurance after deductible 100.00%
Orthodontia – Child
Covered
55.00% Coinsurance after deductible 100.00%
Major Dental Care – Child
Covered
45.00% Coinsurance after deductible 100.00%
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
40.00% Coinsurance after deductible 100.00% Transplants are subject to Case Management.
Accidental Dental
Covered
40.00% Coinsurance after deductible 100.00%
Dialysis
Covered
40.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
40.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
40.00% Coinsurance after deductible 100.00%
Radiation
Covered
40.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
40.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
40.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
40.00% Coinsurance after deductible 100.00% Intravenous administration of nutrients, antibiotics, and other drugs and fluids when provided in the home (home infusion therapy).
Treatment for Temporomandibular Joint Disorders
Covered
40.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Not Covered
Reconstructive Surgery
Covered
40.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Covered
40.00% Coinsurance after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following CareSource Marketplace Standard Silver 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.

Additional Resources

Below are additional resources for CareSource Marketplace Standard Silver 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 Standard Silver?

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

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