Obamacare 2022 Rates for Johnson County

Obamacare > Rates > Missouri > Johnson County

Obamacare is also known as the Affordable Care Act. This page gives you an overview of the rates for individual and family health insurance plans available from , the marketplace for Johnson County, MO.

The health insurance rates listed below are for calendar year 2022.

For information on subsidies to make your coverage affordable, you must take one of the following actions:

  • Contact a licensed health insurance agent
  • Complete an application at Healthcare.gov
  • Contact the provider directly

Obamacare Providers, 49 Plans and 2022 Rates for Johnson County, Missouri

Below, you’ll find a summary of the 49 plans for Johnson County, Missouri and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Blue Cross and Blue Shield of Kansas City

Local: 1-816-395-3558 | Toll Free: 1-888-800-4478

Toc - Plan #1 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Choice Bronze 7000 BlueSelect Plus EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$429.86
$487.89
$549.36
$767.72
$1,166.63 		$758.70
$816.73
$878.20
$1,096.56 		$1,087.54
$1,145.57
$1,207.04
$1,425.40 		$1,416.38
$1,474.41
$1,535.88
$1,754.24 		$328.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.72
$975.78
$1,098.72
$1,535.44
$2,333.26 		$1,188.56
$1,304.62
$1,427.56
$1,864.28 		$1,517.40
$1,633.46
$1,756.40
$2,193.12 		$1,846.24
$1,962.30
$2,085.24
$2,521.96 		$328.84
Toc - Plan #2 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$502.82
$570.70
$642.60
$898.03
$1,364.64 		$887.47
$955.35
$1,027.25
$1,282.68 		$1,272.12
$1,340.00
$1,411.90
$1,667.33 		$1,656.77
$1,724.65
$1,796.55
$2,051.98 		$384.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,005.64
$1,141.40
$1,285.20
$1,796.06
$2,729.28 		$1,390.29
$1,526.05
$1,669.85
$2,180.71 		$1,774.94
$1,910.70
$2,054.50
$2,565.36 		$2,159.59
$2,295.35
$2,439.15
$2,950.01 		$384.65
Toc - Plan #3 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Saver Bronze 6500 with broad Preferred-Care Blue EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$431.06
$489.25
$550.90
$769.87
$1,169.90 		$760.82
$819.01
$880.66
$1,099.63 		$1,090.58
$1,148.77
$1,210.42
$1,429.39 		$1,420.34
$1,478.53
$1,540.18
$1,759.15 		$329.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862.12
$978.50
$1,101.80
$1,539.74
$2,339.80 		$1,191.88
$1,308.26
$1,431.56
$1,869.50 		$1,521.64
$1,638.02
$1,761.32
$2,199.26 		$1,851.40
$1,967.78
$2,091.08
$2,529.02 		$329.76
Toc - Plan #4 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$436.80
$495.77
$558.23
$780.13
$1,185.48 		$770.95
$829.92
$892.38
$1,114.28 		$1,105.10
$1,164.07
$1,226.53
$1,448.43 		$1,439.25
$1,498.22
$1,560.68
$1,782.58 		$334.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$873.60
$991.54
$1,116.46
$1,560.26
$2,370.96 		$1,207.75
$1,325.69
$1,450.61
$1,894.41 		$1,541.90
$1,659.84
$1,784.76
$2,228.56 		$1,876.05
$1,993.99
$2,118.91
$2,562.71 		$334.15
Toc - Plan #5 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Choice Bronze 7000 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$373.48
$423.90
$477.31
$667.04
$1,013.63 		$659.19
$709.61
$763.02
$952.75 		$944.90
$995.32
$1,048.73
$1,238.46 		$1,230.61
$1,281.03
$1,334.44
$1,524.17 		$285.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746.96
$847.80
$954.62
$1,334.08
$2,027.26 		$1,032.67
$1,133.51
$1,240.33
$1,619.79 		$1,318.38
$1,419.22
$1,526.04
$1,905.50 		$1,604.09
$1,704.93
$1,811.75
$2,191.21 		$285.71
Toc - Plan #6 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) BlueKC Community Silver 6000 with broad Preferred-Care Blue EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$521.00
$591.33
$665.83
$930.50
$1,413.98 		$919.56
$989.89
$1,064.39
$1,329.06 		$1,318.12
$1,388.45
$1,462.95
$1,727.62 		$1,716.68
$1,787.01
$1,861.51
$2,126.18 		$398.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,042.00
$1,182.66
$1,331.66
$1,861.00
$2,827.96 		$1,440.56
$1,581.22
$1,730.22
$2,259.56 		$1,839.12
$1,979.78
$2,128.78
$2,658.12 		$2,237.68
$2,378.34
$2,527.34
$3,056.68 		$398.56
Toc - Plan #7 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC First Bronze 7000 with broad Preferred-Care Blue EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$459.32
$521.33
$587.01
$820.35
$1,246.60 		$810.70
$872.71
$938.39
$1,171.73 		$1,162.08
$1,224.09
$1,289.77
$1,523.11 		$1,513.46
$1,575.47
$1,641.15
$1,874.49 		$351.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$918.64
$1,042.66
$1,174.02
$1,640.70
$2,493.20 		$1,270.02
$1,394.04
$1,525.40
$1,992.08 		$1,621.40
$1,745.42
$1,876.78
$2,343.46 		$1,972.78
$2,096.80
$2,228.16
$2,694.84 		$351.38
Toc - Plan #8 Blue Cross and Blue Shield of Kansas City
Gold

(EPO) Blue KC Community Gold 1500 with broad Preferred-Care Blue EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$643.26
$730.09
$822.08
$1,148.85
$1,745.80 		$1,135.35
$1,222.18
$1,314.17
$1,640.94 		$1,627.44
$1,714.27
$1,806.26
$2,133.03 		$2,119.53
$2,206.36
$2,298.35
$2,625.12 		$492.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,286.52
$1,460.18
$1,644.16
$2,297.70
$3,491.60 		$1,778.61
$1,952.27
$2,136.25
$2,789.79 		$2,270.70
$2,444.36
$2,628.34
$3,281.88 		$2,762.79
$2,936.45
$3,120.43
$3,773.97 		$492.09
Toc - Plan #9 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Chocie Bronze 8700 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$344.20
$390.67
$439.89
$614.74
$934.15 		$607.51
$653.98
$703.20
$878.05 		$870.82
$917.29
$966.51
$1,141.36 		$1,134.13
$1,180.60
$1,229.82
$1,404.67 		$263.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.40
$781.34
$879.78
$1,229.48
$1,868.30 		$951.71
$1,044.65
$1,143.09
$1,492.79 		$1,215.02
$1,307.96
$1,406.40
$1,756.10 		$1,478.33
$1,571.27
$1,669.71
$2,019.41 		$263.31
Toc - Plan #10 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 6000 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$416.83
$473.10
$532.71
$744.46
$1,131.28 		$735.71
$791.98
$851.59
$1,063.34 		$1,054.59
$1,110.86
$1,170.47
$1,382.22 		$1,373.47
$1,429.74
$1,489.35
$1,701.10 		$318.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$833.66
$946.20
$1,065.42
$1,488.92
$2,262.56 		$1,152.54
$1,265.08
$1,384.30
$1,807.80 		$1,471.42
$1,583.96
$1,703.18
$2,126.68 		$1,790.30
$1,902.84
$2,022.06
$2,445.56 		$318.88
Toc - Plan #11 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Saver Bronze 6500 with BlueSelect EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$351.66
$399.13
$449.42
$628.06
$954.40 		$620.68
$668.15
$718.44
$897.08 		$889.70
$937.17
$987.46
$1,166.10 		$1,158.72
$1,206.19
$1,256.48
$1,435.12 		$269.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$703.32
$798.26
$898.84
$1,256.12
$1,908.80 		$972.34
$1,067.28
$1,167.86
$1,525.14 		$1,241.36
$1,336.30
$1,436.88
$1,794.16 		$1,510.38
$1,605.32
$1,705.90
$2,063.18 		$269.02

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Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-676-3777
Toc - Plan #12 Medica
Gold

(EPO) Select by Medica Gold Copay ($0 Virtual Care + $5 Generic Drugs + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$850 $2,550 Annual Deductible
$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$488.59
$554.54
$624.40
$872.60
$1,326.00 		$862.35
$928.30
$998.16
$1,246.36 		$1,236.11
$1,302.06
$1,371.92
$1,620.12 		$1,609.87
$1,675.82
$1,745.68
$1,993.88 		$373.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$977.18
$1,109.08
$1,248.80
$1,745.20
$2,652.00 		$1,350.94
$1,482.84
$1,622.56
$2,118.96 		$1,724.70
$1,856.60
$1,996.32
$2,492.72 		$2,098.46
$2,230.36
$2,370.08
$2,866.48 		$373.76
Toc - Plan #13 Medica
Silver

(EPO) Select by Medica Silver Copay ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$442.43
$502.15
$565.41
$790.16
$1,200.73 		$780.88
$840.60
$903.86
$1,128.61 		$1,119.33
$1,179.05
$1,242.31
$1,467.06 		$1,457.78
$1,517.50
$1,580.76
$1,805.51 		$338.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$884.86
$1,004.30
$1,130.82
$1,580.32
$2,401.46 		$1,223.31
$1,342.75
$1,469.27
$1,918.77 		$1,561.76
$1,681.20
$1,807.72
$2,257.22 		$1,900.21
$2,019.65
$2,146.17
$2,595.67 		$338.45
Toc - Plan #14 Medica
Expanded Bronze

(EPO) Select by Medica Bronze H S A ($0 Virtual Care after deductible + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$365.90
$415.28
$467.60
$653.47
$993.01 		$645.80
$695.18
$747.50
$933.37 		$925.70
$975.08
$1,027.40
$1,213.27 		$1,205.60
$1,254.98
$1,307.30
$1,493.17 		$279.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731.80
$830.56
$935.20
$1,306.94
$1,986.02 		$1,011.70
$1,110.46
$1,215.10
$1,586.84 		$1,291.60
$1,390.36
$1,495.00
$1,866.74 		$1,571.50
$1,670.26
$1,774.90
$2,146.64 		$279.90
Toc - Plan #15 Medica
Catastrophic

(EPO) Select by Medica Catastrophic ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$236.77
$268.72
$302.58
$422.85
$642.56 		$417.89
$449.84
$483.70
$603.97 		$599.01
$630.96
$664.82
$785.09 		$780.13
$812.08
$845.94
$966.21 		$181.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$473.54
$537.44
$605.16
$845.70
$1,285.12 		$654.66
$718.56
$786.28
$1,026.82 		$835.78
$899.68
$967.40
$1,207.94 		$1,016.90
$1,080.80
$1,148.52
$1,389.06 		$181.12
Toc - Plan #16 Medica
Gold

(EPO) Select by Medica Gold Share ($0 Virtual Care + $5 Generic Drugs + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,000 $3,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$460.27
$522.40
$588.21
$822.03
$1,249.15 		$812.37
$874.50
$940.31
$1,174.13 		$1,164.47
$1,226.60
$1,292.41
$1,526.23 		$1,516.57
$1,578.70
$1,644.51
$1,878.33 		$352.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$920.54
$1,044.80
$1,176.42
$1,644.06
$2,498.30 		$1,272.64
$1,396.90
$1,528.52
$1,996.16 		$1,624.74
$1,749.00
$1,880.62
$2,348.26 		$1,976.84
$2,101.10
$2,232.72
$2,700.36 		$352.10
Toc - Plan #17 Medica
Expanded Bronze

(EPO) Select by Medica Bronze Share Plus ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$2,300 $6,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$331.26
$375.97
$423.34
$591.62
$899.03 		$584.67
$629.38
$676.75
$845.03 		$838.08
$882.79
$930.16
$1,098.44 		$1,091.49
$1,136.20
$1,183.57
$1,351.85 		$253.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$662.52
$751.94
$846.68
$1,183.24
$1,798.06 		$915.93
$1,005.35
$1,100.09
$1,436.65 		$1,169.34
$1,258.76
$1,353.50
$1,690.06 		$1,422.75
$1,512.17
$1,606.91
$1,943.47 		$253.41
Toc - Plan #18 Medica
Bronze

(EPO) Select by Medica Bronze Value ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$315.02
$357.54
$402.59
$562.62
$854.95 		$556.01
$598.53
$643.58
$803.61 		$797.00
$839.52
$884.57
$1,044.60 		$1,037.99
$1,080.51
$1,125.56
$1,285.59 		$240.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.04
$715.08
$805.18
$1,125.24
$1,709.90 		$871.03
$956.07
$1,046.17
$1,366.23 		$1,112.02
$1,197.06
$1,287.16
$1,607.22 		$1,353.01
$1,438.05
$1,528.15
$1,848.21 		$240.99
Toc - Plan #19 Medica
Bronze

(EPO) Select by Medica Bronze Value + Dental Reimbursement ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$337.39
$382.93
$431.17
$602.56
$915.65 		$595.49
$641.03
$689.27
$860.66 		$853.59
$899.13
$947.37
$1,118.76 		$1,111.69
$1,157.23
$1,205.47
$1,376.86 		$258.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674.78
$765.86
$862.34
$1,205.12
$1,831.30 		$932.88
$1,023.96
$1,120.44
$1,463.22 		$1,190.98
$1,282.06
$1,378.54
$1,721.32 		$1,449.08
$1,540.16
$1,636.64
$1,979.42 		$258.10
Toc - Plan #20 Medica
Expanded Bronze

(EPO) Select by Medica Bronze Copay $0 Preferred Primary Care ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$332.04
$376.86
$424.34
$593.01
$901.14 		$586.04
$630.86
$678.34
$847.01 		$840.04
$884.86
$932.34
$1,101.01 		$1,094.04
$1,138.86
$1,186.34
$1,355.01 		$254.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664.08
$753.72
$848.68
$1,186.02
$1,802.28 		$918.08
$1,007.72
$1,102.68
$1,440.02 		$1,172.08
$1,261.72
$1,356.68
$1,694.02 		$1,426.08
$1,515.72
$1,610.68
$1,948.02 		$254.00

ADVERTISEMENT

Ambetter from Home State Health

Local: 1-855-650-3789 | Toll Free: 1-855-650-3789

Toc - Plan #21 Ambetter from Home State Health
Bronze

(EPO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$373.87
$424.33
$477.79
$667.71
$1,014.65 		$659.87
$710.33
$763.79
$953.71 		$945.87
$996.33
$1,049.79
$1,239.71 		$1,231.87
$1,282.33
$1,335.79
$1,525.71 		$286.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747.74
$848.66
$955.58
$1,335.42
$2,029.30 		$1,033.74
$1,134.66
$1,241.58
$1,621.42 		$1,319.74
$1,420.66
$1,527.58
$1,907.42 		$1,605.74
$1,706.66
$1,813.58
$2,193.42 		$286.00
Toc - Plan #22 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$7,200 $14,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$458.50
$520.39
$585.96
$818.87
$1,244.36 		$809.25
$871.14
$936.71
$1,169.62 		$1,160.00
$1,221.89
$1,287.46
$1,520.37 		$1,510.75
$1,572.64
$1,638.21
$1,871.12 		$350.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917.00
$1,040.78
$1,171.92
$1,637.74
$2,488.72 		$1,267.75
$1,391.53
$1,522.67
$1,988.49 		$1,618.50
$1,742.28
$1,873.42
$2,339.24 		$1,969.25
$2,093.03
$2,224.17
$2,689.99 		$350.75
Toc - Plan #23 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$444.52
$504.52
$568.08
$793.90
$1,206.40 		$784.57
$844.57
$908.13
$1,133.95 		$1,124.62
$1,184.62
$1,248.18
$1,474.00 		$1,464.67
$1,524.67
$1,588.23
$1,814.05 		$340.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$889.04
$1,009.04
$1,136.16
$1,587.80
$2,412.80 		$1,229.09
$1,349.09
$1,476.21
$1,927.85 		$1,569.14
$1,689.14
$1,816.26
$2,267.90 		$1,909.19
$2,029.19
$2,156.31
$2,607.95 		$340.05
Toc - Plan #24 Ambetter from Home State Health
Gold

(EPO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$568.91
$645.70
$727.05
$1,016.06
$1,544.00 		$1,004.12
$1,080.91
$1,162.26
$1,451.27 		$1,439.33
$1,516.12
$1,597.47
$1,886.48 		$1,874.54
$1,951.33
$2,032.68
$2,321.69 		$435.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,137.82
$1,291.40
$1,454.10
$2,032.12
$3,088.00 		$1,573.03
$1,726.61
$1,889.31
$2,467.33 		$2,008.24
$2,161.82
$2,324.52
$2,902.54 		$2,443.45
$2,597.03
$2,759.73
$3,337.75 		$435.21
Toc - Plan #25 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$407.80
$462.84
$521.15
$728.30
$1,106.73 		$719.76
$774.80
$833.11
$1,040.26 		$1,031.72
$1,086.76
$1,145.07
$1,352.22 		$1,343.68
$1,398.72
$1,457.03
$1,664.18 		$311.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.60
$925.68
$1,042.30
$1,456.60
$2,213.46 		$1,127.56
$1,237.64
$1,354.26
$1,768.56 		$1,439.52
$1,549.60
$1,666.22
$2,080.52 		$1,751.48
$1,861.56
$1,978.18
$2,392.48 		$311.96
Toc - Plan #26 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$409.03
$464.24
$522.73
$730.52
$1,110.09 		$721.93
$777.14
$835.63
$1,043.42 		$1,034.83
$1,090.04
$1,148.53
$1,356.32 		$1,347.73
$1,402.94
$1,461.43
$1,669.22 		$312.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.06
$928.48
$1,045.46
$1,461.04
$2,220.18 		$1,130.96
$1,241.38
$1,358.36
$1,773.94 		$1,443.86
$1,554.28
$1,671.26
$2,086.84 		$1,756.76
$1,867.18
$1,984.16
$2,399.74 		$312.90
Toc - Plan #27 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 124

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$452.09
$513.11
$577.75
$807.41
$1,226.93 		$797.93
$858.95
$923.59
$1,153.25 		$1,143.77
$1,204.79
$1,269.43
$1,499.09 		$1,489.61
$1,550.63
$1,615.27
$1,844.93 		$345.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$904.18
$1,026.22
$1,155.50
$1,614.82
$2,453.86 		$1,250.02
$1,372.06
$1,501.34
$1,960.66 		$1,595.86
$1,717.90
$1,847.18
$2,306.50 		$1,941.70
$2,063.74
$2,193.02
$2,652.34 		$345.84
Toc - Plan #28 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 127

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$470.56
$534.08
$601.37
$840.41
$1,277.08 		$830.53
$894.05
$961.34
$1,200.38 		$1,190.50
$1,254.02
$1,321.31
$1,560.35 		$1,550.47
$1,613.99
$1,681.28
$1,920.32 		$359.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$941.12
$1,068.16
$1,202.74
$1,680.82
$2,554.16 		$1,301.09
$1,428.13
$1,562.71
$2,040.79 		$1,661.06
$1,788.10
$1,922.68
$2,400.76 		$2,021.03
$2,148.07
$2,282.65
$2,760.73 		$359.97
Toc - Plan #29 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 129

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$434.11
$492.71
$554.78
$775.31
$1,178.16 		$766.20
$824.80
$886.87
$1,107.40 		$1,098.29
$1,156.89
$1,218.96
$1,439.49 		$1,430.38
$1,488.98
$1,551.05
$1,771.58 		$332.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$868.22
$985.42
$1,109.56
$1,550.62
$2,356.32 		$1,200.31
$1,317.51
$1,441.65
$1,882.71 		$1,532.40
$1,649.60
$1,773.74
$2,214.80 		$1,864.49
$1,981.69
$2,105.83
$2,546.89 		$332.09
Toc - Plan #30 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care 22

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$432.46
$490.83
$552.67
$772.36
$1,173.68 		$763.29
$821.66
$883.50
$1,103.19 		$1,094.12
$1,152.49
$1,214.33
$1,434.02 		$1,424.95
$1,483.32
$1,545.16
$1,764.85 		$330.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$864.92
$981.66
$1,105.34
$1,544.72
$2,347.36 		$1,195.75
$1,312.49
$1,436.17
$1,875.55 		$1,526.58
$1,643.32
$1,767.00
$2,206.38 		$1,857.41
$1,974.15
$2,097.83
$2,537.21 		$330.83
Toc - Plan #31 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$461.44
$523.72
$589.71
$824.11
$1,252.32 		$814.43
$876.71
$942.70
$1,177.10 		$1,167.42
$1,229.70
$1,295.69
$1,530.09 		$1,520.41
$1,582.69
$1,648.68
$1,883.08 		$352.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$922.88
$1,047.44
$1,179.42
$1,648.22
$2,504.64 		$1,275.87
$1,400.43
$1,532.41
$2,001.21 		$1,628.86
$1,753.42
$1,885.40
$2,354.20 		$1,981.85
$2,106.41
$2,238.39
$2,707.19 		$352.99
Toc - Plan #32 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$6,100 $12,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$412.98
$468.72
$527.77
$737.56
$1,120.79 		$728.90
$784.64
$843.69
$1,053.48 		$1,044.82
$1,100.56
$1,159.61
$1,369.40 		$1,360.74
$1,416.48
$1,475.53
$1,685.32 		$315.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.96
$937.44
$1,055.54
$1,475.12
$2,241.58 		$1,141.88
$1,253.36
$1,371.46
$1,791.04 		$1,457.80
$1,569.28
$1,687.38
$2,106.96 		$1,773.72
$1,885.20
$2,003.30
$2,422.88 		$315.92
Toc - Plan #33 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$6,450 $12,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$413.48
$469.29
$528.42
$738.46
$1,122.16 		$729.79
$785.60
$844.73
$1,054.77 		$1,046.10
$1,101.91
$1,161.04
$1,371.08 		$1,362.41
$1,418.22
$1,477.35
$1,687.39 		$316.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$826.96
$938.58
$1,056.84
$1,476.92
$2,244.32 		$1,143.27
$1,254.89
$1,373.15
$1,793.23 		$1,459.58
$1,571.20
$1,689.46
$2,109.54 		$1,775.89
$1,887.51
$2,005.77
$2,425.85 		$316.31
Toc - Plan #34 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$426.41
$483.96
$544.94
$761.55
$1,157.25 		$752.61
$810.16
$871.14
$1,087.75 		$1,078.81
$1,136.36
$1,197.34
$1,413.95 		$1,405.01
$1,462.56
$1,523.54
$1,740.15 		$326.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852.82
$967.92
$1,089.88
$1,523.10
$2,314.50 		$1,179.02
$1,294.12
$1,416.08
$1,849.30 		$1,505.22
$1,620.32
$1,742.28
$2,175.50 		$1,831.42
$1,946.52
$2,068.48
$2,501.70 		$326.20
Toc - Plan #35 Ambetter from Home State Health
Gold

(EPO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$534.48
$606.62
$683.05
$954.56
$1,450.54 		$943.35
$1,015.49
$1,091.92
$1,363.43 		$1,352.22
$1,424.36
$1,500.79
$1,772.30 		$1,761.09
$1,833.23
$1,909.66
$2,181.17 		$408.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,068.96
$1,213.24
$1,366.10
$1,909.12
$2,901.08 		$1,477.83
$1,622.11
$1,774.97
$2,317.99 		$1,886.70
$2,030.98
$2,183.84
$2,726.86 		$2,295.57
$2,439.85
$2,592.71
$3,135.73 		$408.87
Toc - Plan #36 Ambetter from Home State Health
Bronze

(EPO) Ambetter Essential Care 1 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$386.43
$438.59
$493.85
$690.15
$1,048.75 		$682.04
$734.20
$789.46
$985.76 		$977.65
$1,029.81
$1,085.07
$1,281.37 		$1,273.26
$1,325.42
$1,380.68
$1,576.98 		$295.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$772.86
$877.18
$987.70
$1,380.30
$2,097.50 		$1,068.47
$1,172.79
$1,283.31
$1,675.91 		$1,364.08
$1,468.40
$1,578.92
$1,971.52 		$1,659.69
$1,764.01
$1,874.53
$2,267.13 		$295.61
Toc - Plan #37 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care 5 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$421.50
$478.39
$538.67
$752.78
$1,143.93 		$743.94
$800.83
$861.11
$1,075.22 		$1,066.38
$1,123.27
$1,183.55
$1,397.66 		$1,388.82
$1,445.71
$1,505.99
$1,720.10 		$322.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.00
$956.78
$1,077.34
$1,505.56
$2,287.86 		$1,165.44
$1,279.22
$1,399.78
$1,828.00 		$1,487.88
$1,601.66
$1,722.22
$2,150.44 		$1,810.32
$1,924.10
$2,044.66
$2,472.88 		$322.44
Toc - Plan #38 Ambetter from Home State Health
Gold

(EPO) Ambetter Secure Care 5 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$588.03
$667.40
$751.49
$1,050.21
$1,595.89 		$1,037.87
$1,117.24
$1,201.33
$1,500.05 		$1,487.71
$1,567.08
$1,651.17
$1,949.89 		$1,937.55
$2,016.92
$2,101.01
$2,399.73 		$449.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,176.06
$1,334.80
$1,502.98
$2,100.42
$3,191.78 		$1,625.90
$1,784.64
$1,952.82
$2,550.26 		$2,075.74
$2,234.48
$2,402.66
$3,000.10 		$2,525.58
$2,684.32
$2,852.50
$3,449.94 		$449.84
Toc - Plan #39 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 11 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$459.46
$521.48
$587.18
$820.58
$1,246.95 		$810.94
$872.96
$938.66
$1,172.06 		$1,162.42
$1,224.44
$1,290.14
$1,523.54 		$1,513.90
$1,575.92
$1,641.62
$1,875.02 		$351.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$918.92
$1,042.96
$1,174.36
$1,641.16
$2,493.90 		$1,270.40
$1,394.44
$1,525.84
$1,992.64 		$1,621.88
$1,745.92
$1,877.32
$2,344.12 		$1,973.36
$2,097.40
$2,228.80
$2,695.60 		$351.48
Toc - Plan #40 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 4 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$7,200 $14,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$473.91
$537.88
$605.65
$846.39
$1,286.18 		$836.45
$900.42
$968.19
$1,208.93 		$1,198.99
$1,262.96
$1,330.73
$1,571.47 		$1,561.53
$1,625.50
$1,693.27
$1,934.01 		$362.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$947.82
$1,075.76
$1,211.30
$1,692.78
$2,572.36 		$1,310.36
$1,438.30
$1,573.84
$2,055.32 		$1,672.90
$1,800.84
$1,936.38
$2,417.86 		$2,035.44
$2,163.38
$2,298.92
$2,780.40 		$362.54
Toc - Plan #41 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$422.78
$479.84
$540.30
$755.07
$1,147.40 		$746.20
$803.26
$863.72
$1,078.49 		$1,069.62
$1,126.68
$1,187.14
$1,401.91 		$1,393.04
$1,450.10
$1,510.56
$1,725.33 		$323.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.56
$959.68
$1,080.60
$1,510.14
$2,294.80 		$1,168.98
$1,283.10
$1,404.02
$1,833.56 		$1,492.40
$1,606.52
$1,727.44
$2,156.98 		$1,815.82
$1,929.94
$2,050.86
$2,480.40 		$323.42
Toc - Plan #42 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 124 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$467.28
$530.35
$597.17
$834.54
$1,268.17 		$824.74
$887.81
$954.63
$1,192.00 		$1,182.20
$1,245.27
$1,312.09
$1,549.46 		$1,539.66
$1,602.73
$1,669.55
$1,906.92 		$357.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$934.56
$1,060.70
$1,194.34
$1,669.08
$2,536.34 		$1,292.02
$1,418.16
$1,551.80
$2,026.54 		$1,649.48
$1,775.62
$1,909.26
$2,384.00 		$2,006.94
$2,133.08
$2,266.72
$2,741.46 		$357.46
Toc - Plan #43 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 127 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$486.38
$552.03
$621.58
$868.65
$1,320.00 		$858.45
$924.10
$993.65
$1,240.72 		$1,230.52
$1,296.17
$1,365.72
$1,612.79 		$1,602.59
$1,668.24
$1,737.79
$1,984.86 		$372.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$972.76
$1,104.06
$1,243.16
$1,737.30
$2,640.00 		$1,344.83
$1,476.13
$1,615.23
$2,109.37 		$1,716.90
$1,848.20
$1,987.30
$2,481.44 		$2,088.97
$2,220.27
$2,359.37
$2,853.51 		$372.07
Toc - Plan #44 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care 22 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$447.00
$507.33
$571.25
$798.32
$1,213.12 		$788.94
$849.27
$913.19
$1,140.26 		$1,130.88
$1,191.21
$1,255.13
$1,482.20 		$1,472.82
$1,533.15
$1,597.07
$1,824.14 		$341.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$894.00
$1,014.66
$1,142.50
$1,596.64
$2,426.24 		$1,235.94
$1,356.60
$1,484.44
$1,938.58 		$1,577.88
$1,698.54
$1,826.38
$2,280.52 		$1,919.82
$2,040.48
$2,168.32
$2,622.46 		$341.94
Toc - Plan #45 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care: $0 Medical Deductible + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$476.95
$541.32
$609.53
$851.81
$1,294.41 		$841.81
$906.18
$974.39
$1,216.67 		$1,206.67
$1,271.04
$1,339.25
$1,581.53 		$1,571.53
$1,635.90
$1,704.11
$1,946.39 		$364.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$953.90
$1,082.64
$1,219.06
$1,703.62
$2,588.82 		$1,318.76
$1,447.50
$1,583.92
$2,068.48 		$1,683.62
$1,812.36
$1,948.78
$2,433.34 		$2,048.48
$2,177.22
$2,313.64
$2,798.20 		$364.86
Toc - Plan #46 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 31 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$6,450 $12,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$427.38
$485.06
$546.18
$763.28
$1,159.87 		$754.32
$812.00
$873.12
$1,090.22 		$1,081.26
$1,138.94
$1,200.06
$1,417.16 		$1,408.20
$1,465.88
$1,527.00
$1,744.10 		$326.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.76
$970.12
$1,092.36
$1,526.56
$2,319.74 		$1,181.70
$1,297.06
$1,419.30
$1,853.50 		$1,508.64
$1,624.00
$1,746.24
$2,180.44 		$1,835.58
$1,950.94
$2,073.18
$2,507.38 		$326.94
Toc - Plan #47 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 32 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$440.74
$500.23
$563.25
$787.15
$1,196.14 		$777.90
$837.39
$900.41
$1,124.31 		$1,115.06
$1,174.55
$1,237.57
$1,461.47 		$1,452.22
$1,511.71
$1,574.73
$1,798.63 		$337.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$881.48
$1,000.46
$1,126.50
$1,574.30
$2,392.28 		$1,218.64
$1,337.62
$1,463.66
$1,911.46 		$1,555.80
$1,674.78
$1,800.82
$2,248.62 		$1,892.96
$2,011.94
$2,137.98
$2,585.78 		$337.16
Toc - Plan #48 Ambetter from Home State Health
Gold

(EPO) Ambetter Secure Care 20 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$552.44
$627.01
$706.01
$986.64
$1,499.30 		$975.05
$1,049.62
$1,128.62
$1,409.25 		$1,397.66
$1,472.23
$1,551.23
$1,831.86 		$1,820.27
$1,894.84
$1,973.84
$2,254.47 		$422.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,104.88
$1,254.02
$1,412.02
$1,973.28
$2,998.60 		$1,527.49
$1,676.63
$1,834.63
$2,395.89 		$1,950.10
$2,099.24
$2,257.24
$2,818.50 		$2,372.71
$2,521.85
$2,679.85
$3,241.11 		$422.61
Toc - Plan #49 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 129 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$448.70
$509.27
$573.43
$801.37
$1,217.75 		$791.95
$852.52
$916.68
$1,144.62 		$1,135.20
$1,195.77
$1,259.93
$1,487.87 		$1,478.45
$1,539.02
$1,603.18
$1,831.12 		$343.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$897.40
$1,018.54
$1,146.86
$1,602.74
$2,435.50 		$1,240.65
$1,361.79
$1,490.11
$1,945.99 		$1,583.90
$1,705.04
$1,833.36
$2,289.24 		$1,927.15
$2,048.29
$2,176.61
$2,632.49 		$343.25

‡Source: HealthCare.gov has released sample rates for all counties in the 36 states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Johnson County here.

Johnson County is in “Rating Area 4” of Missouri.

Currently, there are 49 plans offered in Rating Area 4.

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2022 Obamacare Plans for Johnson County, MO

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