Obamacare 2021 Rates for Ray County

Obamacare > Rates > Missouri > Ray 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 Ray County, MO.

The health insurance rates listed below are for calendar year 2021.

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, 36 Plans and 2021 Rates for Ray County, Missouri

Below, you’ll find a summary of the 36 plans for Ray 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 Saver Preferred-Care Blue 6500 (Telehealth: $10 Copay for Primary Care Office Visit & Behavioral Health Therapy; $0 Preventive Care)

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
$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 		$431,67
$489,95
$551,68
$770,97
$1 171,56 		$761,90
$820,18
$881,91
$1 101,20 		$1 092,13
$1 150,41
$1 212,14
$1 431,43 		$1 422,36
$1 480,64
$1 542,37
$1 761,66 		$330,23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$863,34
$979,90
$1 103,36
$1 541,94
$2 343,12 		$1 193,57
$1 310,13
$1 433,59
$1 872,17 		$1 523,80
$1 640,36
$1 763,82
$2 202,40 		$1 854,03
$1 970,59
$2 094,05
$2 532,63 		$330,23
Toc - Plan #2 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Community Preferred-Care Blue 3375 (Telehealth: $10 Copay for Primary Care Office Visit & Behavioral Health Therapy; $0 Preventive Care)

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

Annual Out of Pocket Expenses:

Individual Family
$3,375 $6,750 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 		$513,41
$582,72
$656,14
$916,95
$1 393,39 		$906,17
$975,48
$1 048,90
$1 309,71 		$1 298,93
$1 368,24
$1 441,66
$1 702,47 		$1 691,69
$1 761,00
$1 834,42
$2 095,23 		$392,76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 026,82
$1 165,44
$1 312,28
$1 833,90
$2 786,78 		$1 419,58
$1 558,20
$1 705,04
$2 226,66 		$1 812,34
$1 950,96
$2 097,80
$2 619,42 		$2 205,10
$2 343,72
$2 490,56
$3 012,18 		$392,76
Toc - Plan #3 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Community Preferred-Care Blue 5750 (Telehealth: $10 Copay for Primary Care Office Visit & Behavioral Health Therapy; $0 Preventive Care)

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

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$7,750 $15,500 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 		$509,47
$578,25
$651,11
$909,92
$1 382,71 		$899,22
$968,00
$1 040,86
$1 299,67 		$1 288,97
$1 357,75
$1 430,61
$1 689,42 		$1 678,72
$1 747,50
$1 820,36
$2 079,17 		$389,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 018,94
$1 156,50
$1 302,22
$1 819,84
$2 765,42 		$1 408,69
$1 546,25
$1 691,97
$2 209,59 		$1 798,44
$1 936,00
$2 081,72
$2 599,34 		$2 188,19
$2 325,75
$2 471,47
$2 989,09 		$389,75
Toc - Plan #4 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Community Preferred-Care Blue 6000 (Telehealth: $10 Copay for Primary Care Office Visit & Behavioral Health Therapy; $0 Preventive 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
$8,100 $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 		$491,65
$558,03
$628,33
$878,09
$1 334,35 		$867,76
$934,14
$1 004,44
$1 254,20 		$1 243,87
$1 310,25
$1 380,55
$1 630,31 		$1 619,98
$1 686,36
$1 756,66
$2 006,42 		$376,11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$983,30
$1 116,06
$1 256,66
$1 756,18
$2 668,70 		$1 359,41
$1 492,17
$1 632,77
$2 132,29 		$1 735,52
$1 868,28
$2 008,88
$2 508,40 		$2 111,63
$2 244,39
$2 384,99
$2 884,51 		$376,11
Toc - Plan #5 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC First Preferred-Care Blue 7000 (Telehealth: $10 Copay for Primary Care Office Visit & Behavioral Health Therapy;Ê$0ÊPreventive Care)Ê

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 		$408,23
$463,34
$521,72
$729,10
$1 107,94 		$720,53
$775,64
$834,02
$1 041,40 		$1 032,83
$1 087,94
$1 146,32
$1 353,70 		$1 345,13
$1 400,24
$1 458,62
$1 666,00 		$312,30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816,46
$926,68
$1 043,44
$1 458,20
$2 215,88 		$1 128,76
$1 238,98
$1 355,74
$1 770,50 		$1 441,06
$1 551,28
$1 668,04
$2 082,80 		$1 753,36
$1 863,58
$1 980,34
$2 395,10 		$312,30
Toc - Plan #6 Blue Cross and Blue Shield of Kansas City
Gold

(EPO) Blue KC First Preferred-Care Blue 1500 (Telehealth: $10 Copay for Primary Care Office Visit & Behavioral Health Therapy;Ê$0ÊPreventive Care)Ê

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
$5,750 $11,500 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 		$589,35
$668,92
$753,19
$1 052,59
$1 599,51 		$1 040,21
$1 119,78
$1 204,05
$1 503,45 		$1 491,07
$1 570,64
$1 654,91
$1 954,31 		$1 941,93
$2 021,50
$2 105,77
$2 405,17 		$450,86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 178,70
$1 337,84
$1 506,38
$2 105,18
$3 199,02 		$1 629,56
$1 788,70
$1 957,24
$2 556,04 		$2 080,42
$2 239,56
$2 408,10
$3 006,90 		$2 531,28
$2 690,42
$2 858,96
$3 457,76 		$450,86

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Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #7 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 5900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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 		$380,25
$431,58
$485,95
$679,12
$1 031,99 		$671,14
$722,47
$776,84
$970,01 		$962,03
$1 013,36
$1 067,73
$1 260,90 		$1 252,92
$1 304,25
$1 358,62
$1 551,79 		$290,89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760,50
$863,16
$971,90
$1 358,24
$2 063,98 		$1 051,39
$1 154,05
$1 262,79
$1 649,13 		$1 342,28
$1 444,94
$1 553,68
$1 940,02 		$1 633,17
$1 735,83
$1 844,57
$2 230,91 		$290,89
Toc - Plan #8 Cigna Healthcare
Silver

(EPO) Cigna Connect 5500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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 		$453,17
$514,35
$579,16
$809,37
$1 229,91 		$799,85
$861,03
$925,84
$1 156,05 		$1 146,53
$1 207,71
$1 272,52
$1 502,73 		$1 493,21
$1 554,39
$1 619,20
$1 849,41 		$346,68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$906,34
$1 028,70
$1 158,32
$1 618,74
$2 459,82 		$1 253,02
$1 375,38
$1 505,00
$1 965,42 		$1 599,70
$1 722,06
$1 851,68
$2 312,10 		$1 946,38
$2 068,74
$2 198,36
$2 658,78 		$346,68
Toc - Plan #9 Cigna Healthcare
Silver

(EPO) Cigna Connect 2900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$2,900 $5,800 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 		$458,55
$520,46
$586,03
$818,98
$1 244,52 		$809,34
$871,25
$936,82
$1 169,77 		$1 160,13
$1 222,04
$1 287,61
$1 520,56 		$1 510,92
$1 572,83
$1 638,40
$1 871,35 		$350,79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917,10
$1 040,92
$1 172,06
$1 637,96
$2 489,04 		$1 267,89
$1 391,71
$1 522,85
$1 988,75 		$1 618,68
$1 742,50
$1 873,64
$2 339,54 		$1 969,47
$2 093,29
$2 224,43
$2 690,33 		$350,79
Toc - Plan #10 Cigna Healthcare
Gold

(EPO) Cigna Connect 1000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$573,67
$651,12
$733,15
$1 024,58
$1 556,95 		$1 012,53
$1 089,98
$1 172,01
$1 463,44 		$1 451,39
$1 528,84
$1 610,87
$1 902,30 		$1 890,25
$1 967,70
$2 049,73
$2 341,16 		$438,86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 147,34
$1 302,24
$1 466,30
$2 049,16
$3 113,90 		$1 586,20
$1 741,10
$1 905,16
$2 488,02 		$2 025,06
$2 179,96
$2 344,02
$2 926,88 		$2 463,92
$2 618,82
$2 782,88
$3 365,74 		$438,86
Toc - Plan #11 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 7000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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 		$375,77
$426,50
$480,24
$671,13
$1 019,84 		$663,24
$713,97
$767,71
$958,60 		$950,71
$1 001,44
$1 055,18
$1 246,07 		$1 238,18
$1 288,91
$1 342,65
$1 533,54 		$287,47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751,54
$853,00
$960,48
$1 342,26
$2 039,68 		$1 039,01
$1 140,47
$1 247,95
$1 629,73 		$1 326,48
$1 427,94
$1 535,42
$1 917,20 		$1 613,95
$1 715,41
$1 822,89
$2 204,67 		$287,47
Toc - Plan #12 Cigna Healthcare
Bronze

(EPO) Cigna Connect 8550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 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 		$364,11
$413,26
$465,33
$650,29
$988,18 		$642,65
$691,80
$743,87
$928,83 		$921,19
$970,34
$1 022,41
$1 207,37 		$1 199,73
$1 248,88
$1 300,95
$1 485,91 		$278,54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728,22
$826,52
$930,66
$1 300,58
$1 976,36 		$1 006,76
$1 105,06
$1 209,20
$1 579,12 		$1 285,30
$1 383,60
$1 487,74
$1 857,66 		$1 563,84
$1 662,14
$1 766,28
$2 136,20 		$278,54
Toc - Plan #13 Cigna Healthcare
Silver

(EPO) Cigna Connect 7300

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$7,300 $14,600 Annual Deductible
$7,300 $14,600 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 		$454,35
$515,68
$580,65
$811,46
$1 233,09 		$801,92
$863,25
$928,22
$1 159,03 		$1 149,49
$1 210,82
$1 275,79
$1 506,60 		$1 497,06
$1 558,39
$1 623,36
$1 854,17 		$347,57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$908,70
$1 031,36
$1 161,30
$1 622,92
$2 466,18 		$1 256,27
$1 378,93
$1 508,87
$1 970,49 		$1 603,84
$1 726,50
$1 856,44
$2 318,06 		$1 951,41
$2 074,07
$2 204,01
$2 665,63 		$347,57
Toc - Plan #14 Cigna Healthcare
Silver

(EPO) Cigna Connect 4500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$454,40
$515,74
$580,72
$811,56
$1 233,24 		$802,02
$863,36
$928,34
$1 159,18 		$1 149,64
$1 210,98
$1 275,96
$1 506,80 		$1 497,26
$1 558,60
$1 623,58
$1 854,42 		$347,62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$908,80
$1 031,48
$1 161,44
$1 623,12
$2 466,48 		$1 256,42
$1 379,10
$1 509,06
$1 970,74 		$1 604,04
$1 726,72
$1 856,68
$2 318,36 		$1 951,66
$2 074,34
$2 204,30
$2 665,98 		$347,62
Toc - Plan #15 Cigna Healthcare
Silver

(EPO) Cigna Connect 3500 Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$454,99
$516,41
$581,47
$812,60
$1 234,83 		$803,05
$864,47
$929,53
$1 160,66 		$1 151,11
$1 212,53
$1 277,59
$1 508,72 		$1 499,17
$1 560,59
$1 625,65
$1 856,78 		$348,06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$909,98
$1 032,82
$1 162,94
$1 625,20
$2 469,66 		$1 258,04
$1 380,88
$1 511,00
$1 973,26 		$1 606,10
$1 728,94
$1 859,06
$2 321,32 		$1 954,16
$2 077,00
$2 207,12
$2 669,38 		$348,06

ADVERTISEMENT

Ambetter from Home State Health

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

Toc - Plan #16 Ambetter from Home State Health
Bronze

(EPO) Ambetter Essential Care 1 (2021)

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
$8,300 $16,600 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 		$360,99
$409,71
$461,33
$644,70
$979,69 		$637,14
$685,86
$737,48
$920,85 		$913,29
$962,01
$1 013,63
$1 197,00 		$1 189,44
$1 238,16
$1 289,78
$1 473,15 		$276,15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721,98
$819,42
$922,66
$1 289,40
$1 959,38 		$998,13
$1 095,57
$1 198,81
$1 565,55 		$1 274,28
$1 371,72
$1 474,96
$1 841,70 		$1 550,43
$1 647,87
$1 751,11
$2 117,85 		$276,15
Toc - Plan #17 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 4 (2021)

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 		$436,39
$495,29
$557,70
$779,38
$1 184,34 		$770,22
$829,12
$891,53
$1 113,21 		$1 104,05
$1 162,95
$1 225,36
$1 447,04 		$1 437,88
$1 496,78
$1 559,19
$1 780,87 		$333,83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$872,78
$990,58
$1 115,40
$1 558,76
$2 368,68 		$1 206,61
$1 324,41
$1 449,23
$1 892,59 		$1 540,44
$1 658,24
$1 783,06
$2 226,42 		$1 874,27
$1 992,07
$2 116,89
$2 560,25 		$333,83
Toc - Plan #18 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 11 (2021)

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 		$422,73
$479,79
$540,24
$754,98
$1 147,27 		$746,11
$803,17
$863,62
$1 078,36 		$1 069,49
$1 126,55
$1 187,00
$1 401,74 		$1 392,87
$1 449,93
$1 510,38
$1 725,12 		$323,38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845,46
$959,58
$1 080,48
$1 509,96
$2 294,54 		$1 168,84
$1 282,96
$1 403,86
$1 833,34 		$1 492,22
$1 606,34
$1 727,24
$2 156,72 		$1 815,60
$1 929,72
$2 050,62
$2 480,10 		$323,38
Toc - Plan #19 Ambetter from Home State Health
Gold

(EPO) Ambetter Secure Care 5 (2021)

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 		$550,11
$624,37
$703,03
$982,48
$1 492,98 		$970,94
$1 045,20
$1 123,86
$1 403,31 		$1 391,77
$1 466,03
$1 544,69
$1 824,14 		$1 812,60
$1 886,86
$1 965,52
$2 244,97 		$420,83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 100,22
$1 248,74
$1 406,06
$1 964,96
$2 985,96 		$1 521,05
$1 669,57
$1 826,89
$2 385,79 		$1 941,88
$2 090,40
$2 247,72
$2 806,62 		$2 362,71
$2 511,23
$2 668,55
$3 227,45 		$420,83
Toc - Plan #20 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care 5 (2021)

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
$8,500 $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 		$389,22
$441,75
$497,41
$695,13
$1 056,31 		$686,97
$739,50
$795,16
$992,88 		$984,72
$1 037,25
$1 092,91
$1 290,63 		$1 282,47
$1 335,00
$1 390,66
$1 588,38 		$297,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778,44
$883,50
$994,82
$1 390,26
$2 112,62 		$1 076,19
$1 181,25
$1 292,57
$1 688,01 		$1 373,94
$1 479,00
$1 590,32
$1 985,76 		$1 671,69
$1 776,75
$1 888,07
$2 283,51 		$297,75
Toc - Plan #21 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA (2021)

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 		$390,92
$443,68
$499,58
$698,17
$1 060,93 		$689,97
$742,73
$798,63
$997,22 		$989,02
$1 041,78
$1 097,68
$1 296,27 		$1 288,07
$1 340,83
$1 396,73
$1 595,32 		$299,05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781,84
$887,36
$999,16
$1 396,34
$2 121,86 		$1 080,89
$1 186,41
$1 298,21
$1 695,39 		$1 379,94
$1 485,46
$1 597,26
$1 994,44 		$1 678,99
$1 784,51
$1 896,31
$2 293,49 		$299,05
Toc - Plan #22 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 126 (2021)

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
$8,100 $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 		$434,04
$492,62
$554,69
$775,17
$1 177,95 		$766,07
$824,65
$886,72
$1 107,20 		$1 098,10
$1 156,68
$1 218,75
$1 439,23 		$1 430,13
$1 488,71
$1 550,78
$1 771,26 		$332,03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$868,08
$985,24
$1 109,38
$1 550,34
$2 355,90 		$1 200,11
$1 317,27
$1 441,41
$1 882,37 		$1 532,14
$1 649,30
$1 773,44
$2 214,40 		$1 864,17
$1 981,33
$2 105,47
$2 546,43 		$332,03
Toc - Plan #23 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 124 (2021)

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 		$429,45
$487,42
$548,83
$766,99
$1 165,51 		$757,97
$815,94
$877,35
$1 095,51 		$1 086,49
$1 144,46
$1 205,87
$1 424,03 		$1 415,01
$1 472,98
$1 534,39
$1 752,55 		$328,52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$858,90
$974,84
$1 097,66
$1 533,98
$2 331,02 		$1 187,42
$1 303,36
$1 426,18
$1 862,50 		$1 515,94
$1 631,88
$1 754,70
$2 191,02 		$1 844,46
$1 960,40
$2 083,22
$2 519,54 		$328,52
Toc - Plan #24 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 127 (2021)

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 		$450,66
$511,49
$575,93
$804,86
$1 223,07 		$795,41
$856,24
$920,68
$1 149,61 		$1 140,16
$1 200,99
$1 265,43
$1 494,36 		$1 484,91
$1 545,74
$1 610,18
$1 839,11 		$344,75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$901,32
$1 022,98
$1 151,86
$1 609,72
$2 446,14 		$1 246,07
$1 367,73
$1 496,61
$1 954,47 		$1 590,82
$1 712,48
$1 841,36
$2 299,22 		$1 935,57
$2 057,23
$2 186,11
$2 643,97 		$344,75
Toc - Plan #25 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 128 (2021)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 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 		$448,00
$508,47
$572,53
$800,11
$1 215,85 		$790,71
$851,18
$915,24
$1 142,82 		$1 133,42
$1 193,89
$1 257,95
$1 485,53 		$1 476,13
$1 536,60
$1 600,66
$1 828,24 		$342,71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$896,00
$1 016,94
$1 145,06
$1 600,22
$2 431,70 		$1 238,71
$1 359,65
$1 487,77
$1 942,93 		$1 581,42
$1 702,36
$1 830,48
$2 285,64 		$1 924,13
$2 045,07
$2 173,19
$2 628,35 		$342,71
Toc - Plan #26 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 129 (2021)

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
$8,400 $16,800 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 		$408,64
$463,79
$522,23
$729,81
$1 109,02 		$721,24
$776,39
$834,83
$1 042,41 		$1 033,84
$1 088,99
$1 147,43
$1 355,01 		$1 346,44
$1 401,59
$1 460,03
$1 667,61 		$312,60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$817,28
$927,58
$1 044,46
$1 459,62
$2 218,04 		$1 129,88
$1 240,18
$1 357,06
$1 772,22 		$1 442,48
$1 552,78
$1 669,66
$2 084,82 		$1 755,08
$1 865,38
$1 982,26
$2 397,42 		$312,60
Toc - Plan #27 Ambetter from Home State Health
Bronze

(EPO) Ambetter Essential Care 1 (2021) + 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
$8,300 $16,600 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 		$375,08
$425,70
$479,33
$669,87
$1 017,93 		$662,00
$712,62
$766,25
$956,79 		$948,92
$999,54
$1 053,17
$1 243,71 		$1 235,84
$1 286,46
$1 340,09
$1 530,63 		$286,92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750,16
$851,40
$958,66
$1 339,74
$2 035,86 		$1 037,08
$1 138,32
$1 245,58
$1 626,66 		$1 324,00
$1 425,24
$1 532,50
$1 913,58 		$1 610,92
$1 712,16
$1 819,42
$2 200,50 		$286,92
Toc - Plan #28 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care 5 (2021) + 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
$8,500 $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 		$404,41
$459,00
$516,82
$722,26
$1 097,54 		$713,78
$768,37
$826,19
$1 031,63 		$1 023,15
$1 077,74
$1 135,56
$1 341,00 		$1 332,52
$1 387,11
$1 444,93
$1 650,37 		$309,37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$808,82
$918,00
$1 033,64
$1 444,52
$2 195,08 		$1 118,19
$1 227,37
$1 343,01
$1 753,89 		$1 427,56
$1 536,74
$1 652,38
$2 063,26 		$1 736,93
$1 846,11
$1 961,75
$2 372,63 		$309,37
Toc - Plan #29 Ambetter from Home State Health
Gold

(EPO) Ambetter Secure Care 5 (2021) + 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 		$571,59
$648,74
$730,47
$1 020,83
$1 551,26 		$1 008,85
$1 086,00
$1 167,73
$1 458,09 		$1 446,11
$1 523,26
$1 604,99
$1 895,35 		$1 883,37
$1 960,52
$2 042,25
$2 332,61 		$437,26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1 143,18
$1 297,48
$1 460,94
$2 041,66
$3 102,52 		$1 580,44
$1 734,74
$1 898,20
$2 478,92 		$2 017,70
$2 172,00
$2 335,46
$2 916,18 		$2 454,96
$2 609,26
$2 772,72
$3 353,44 		$437,26
Toc - Plan #30 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 11 (2021) + 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 		$439,23
$498,52
$561,33
$784,45
$1 192,05 		$775,24
$834,53
$897,34
$1 120,46 		$1 111,25
$1 170,54
$1 233,35
$1 456,47 		$1 447,26
$1 506,55
$1 569,36
$1 792,48 		$336,01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878,46
$997,04
$1 122,66
$1 568,90
$2 384,10 		$1 214,47
$1 333,05
$1 458,67
$1 904,91 		$1 550,48
$1 669,06
$1 794,68
$2 240,92 		$1 886,49
$2 005,07
$2 130,69
$2 576,93 		$336,01
Toc - Plan #31 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 4 (2021) + 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 		$453,43
$514,63
$579,46
$809,80
$1 230,57 		$800,29
$861,49
$926,32
$1 156,66 		$1 147,15
$1 208,35
$1 273,18
$1 503,52 		$1 494,01
$1 555,21
$1 620,04
$1 850,38 		$346,86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$906,86
$1 029,26
$1 158,92
$1 619,60
$2 461,14 		$1 253,72
$1 376,12
$1 505,78
$1 966,46 		$1 600,58
$1 722,98
$1 852,64
$2 313,32 		$1 947,44
$2 069,84
$2 199,50
$2 660,18 		$346,86
Toc - Plan #32 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA (2021) + 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 		$406,18
$461,00
$519,08
$725,42
$1 102,34 		$716,90
$771,72
$829,80
$1 036,14 		$1 027,62
$1 082,44
$1 140,52
$1 346,86 		$1 338,34
$1 393,16
$1 451,24
$1 657,58 		$310,72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812,36
$922,00
$1 038,16
$1 450,84
$2 204,68 		$1 123,08
$1 232,72
$1 348,88
$1 761,56 		$1 433,80
$1 543,44
$1 659,60
$2 072,28 		$1 744,52
$1 854,16
$1 970,32
$2 383,00 		$310,72
Toc - Plan #33 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 126 (2021) + 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
$8,100 $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 		$450,98
$511,85
$576,34
$805,43
$1 223,92 		$795,97
$856,84
$921,33
$1 150,42 		$1 140,96
$1 201,83
$1 266,32
$1 495,41 		$1 485,95
$1 546,82
$1 611,31
$1 840,40 		$344,99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$901,96
$1 023,70
$1 152,68
$1 610,86
$2 447,84 		$1 246,95
$1 368,69
$1 497,67
$1 955,85 		$1 591,94
$1 713,68
$1 842,66
$2 300,84 		$1 936,93
$2 058,67
$2 187,65
$2 645,83 		$344,99
Toc - Plan #34 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 124 (2021) + 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 		$446,22
$506,44
$570,25
$796,92
$1 211,00 		$787,57
$847,79
$911,60
$1 138,27 		$1 128,92
$1 189,14
$1 252,95
$1 479,62 		$1 470,27
$1 530,49
$1 594,30
$1 820,97 		$341,35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$892,44
$1 012,88
$1 140,50
$1 593,84
$2 422,00 		$1 233,79
$1 354,23
$1 481,85
$1 935,19 		$1 575,14
$1 695,58
$1 823,20
$2 276,54 		$1 916,49
$2 036,93
$2 164,55
$2 617,89 		$341,35
Toc - Plan #35 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 127 (2021) + 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 		$468,25
$531,45
$598,41
$836,28
$1 270,81 		$826,46
$889,66
$956,62
$1 194,49 		$1 184,67
$1 247,87
$1 314,83
$1 552,70 		$1 542,88
$1 606,08
$1 673,04
$1 910,91 		$358,21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$936,50
$1 062,90
$1 196,82
$1 672,56
$2 541,62 		$1 294,71
$1 421,11
$1 555,03
$2 030,77 		$1 652,92
$1 779,32
$1 913,24
$2 388,98 		$2 011,13
$2 137,53
$2 271,45
$2 747,19 		$358,21
Toc - Plan #36 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 128 (2021) + 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
$8,200 $16,400 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 		$465,49
$528,32
$594,88
$831,34
$1 263,30 		$821,58
$884,41
$950,97
$1 187,43 		$1 177,67
$1 240,50
$1 307,06
$1 543,52 		$1 533,76
$1 596,59
$1 663,15
$1 899,61 		$356,09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$930,98
$1 056,64
$1 189,76
$1 662,68
$2 526,60 		$1 287,07
$1 412,73
$1 545,85
$2 018,77 		$1 643,16
$1 768,82
$1 901,94
$2 374,86 		$1 999,25
$2 124,91
$2 258,03
$2 730,95 		$356,09

‡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 Ray County here.

Ray County is in “Rating Area 1” of Missouri.

Currently, there are 36 plans offered in Rating Area 1.

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