Limited Cost Share and Zero Cost Share Plans (2022)
Summary of Benefits And Coverage (SBCs) for Individual Zero Cost Sharing and Limited Cost Sharing Plans
In compliance with requirements of the Affordable Care Act, AdventHealth Advantage Plans has made available a Summary of Benefits and Coverage (SBC) for your plan. The SBC summarizes important information about your health coverage in a standardized format. Each SBC will display as a PDF, and you will need Adobe Reader to view it. You can download Acrobat Reader for free using the link at the bottom of this page. If you aren't clear about any of the underlined terms used in these forms, see the Glossary.
The SBCs below are provided for limited cost sharing and zero cost sharing plans. Limited cost sharing plans are available to members of the federally recognized tribes and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders, regardless of income or eligibility for premium tax credits. Zero cost sharing plans are available to members of the federally recognized tribes and ANCSA Corporation shareholders whose income is between 100% and 300% of the federal poverty level and qualify for premium tax credits. Eligibility for these plans is determined by the Marketplace.
Limited Cost Share Plans
HMO
AdventHealth GYM ACCESS Gold HMO 90 HSA 1745 LIMITED AdventHealth GYM ACCESS Silver HMO 80 1696 LIMITED AdventHealth GYM ACCESS Gold HMO 70 1743 LIMITED AdventHealth GYM ACCESS Gold HMO 100 1738 LIMITED AdventHealth GYM ACCESS Gold HMO 80 1741 LIMITED AdventHealth GYM ACCESS Silver HMO 100 1668 LIMITED AdventHealth GYM ACCESS Bronze HMO 100 HSA 1660 LIMITED AdventHealth GYM ACCESS Bronze HMO 50 1797 LIMITED AdventHealth GYM ACCESS Bronze HMO 60 1657 LIMITED AdventHealth Bronze HMO 60 1752 LIMITED AdventHealth Gold HMO 80 1772 LIMITED AdventHealth Bronze HMO 100 1776 LIMITED AdventHealth Bronze HMO 100 HSA 1795 LIMITED AdventHealth Silver HMO 65 1810 LIMITED AdventHealth Bronze VALUE RX 50 1820 LIMITED AdventHealth Silver VALUE RX 80 1821 LIMITED AdventHealth Gold VALUE RX 75 1825 LIMITED
Zero Cost Share Plans
HMO
AdventHealth GYM ACCESS Gold HMO 90 HSA 1745 ZERO AdventHealth GYM ACCESS Silver HMO 80 1696 ZERO AdventHealth GYM ACCESS Gold HMO 70 1743 ZERO AdventHealth GYM ACCESS Gold HMO 100 1738 ZERO AdventHealth GYM ACCESS Gold HMO 80 1741 ZERO AdventHealth GYM ACCESS Silver HMO 100 1668 ZERO AdventHealth GYM ACCESS Bronze HMO 100 HSA 1660 ZERO AdventHealth GYM ACCESS Bronze HMO 50 1797 ZERO AdventHealth GYM ACCESS Bronze HMO 60 1657 ZERO AdventHealth Bronze HMO 60 1752 ZERO AdventHealth Gold HMO 80 1772 ZERO AdventHealth Bronze HMO 100 1776 ZERO AdventHealth Bronze HMO 100 HSA 1795 ZERO AdventHealth Silver HMO 65 1810 ZERO AdventHealth Bronze VALUE RX 50 1820 ZERO AdventHealth Silver VALUE RX 80 1821 ZERO AdventHealth Gold VALUE RX 75 1825 ZERO
A paper copy of your SBC is also available, free of charge, by calling Customer Service toll-free at 1.844.522.5269 (TTY/TDD relay: 1.800.955.8771) weekdays from 8 a.m. to 6 p.m.