Capital Health Plan HMO Gold 3000 - 66966FL0050003 Health Insurance Plan
Capital Health Plan health insurance plan with the Plan ID 66966FL0050003. The plan is called Capital Health Plan HMO Gold 3000.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.27% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.73% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 66966FL0050003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Florida | ||||||||||||||||||
| Health Insurance Issuer | Capital Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 66966FL0050003-01 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 66966FL0050003-00 Standard On Exchange Plan - 66966FL0050003-01 |
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| Last Plan Update Date | Thu, 17 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Capital Health Plan HMO Gold 3000 Health Insurance Plan, 66966FL0050003-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | Tier 1: $750.00 Tier 2: $750.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | Tier 1: $50.00 Tier 2: $50.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | Tier 1: $750.00 Tier 2: $750.00 |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | Tier 1: $50.00 Tier 2: $50.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
per day up to 5 days |
YES | Tier 1: $750.00 Tier 2: $750.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Dialysis
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Durable Medical Equipment
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Emergency Room Services
Coinsurance and Copayment is waived if inpatient admission occurs; however if moved to observation status an additional copayment may apply based on services rendered. |
YES | Tier 1: $350.00 Tier 2: $350.00 |
$350.00 |
| Emergency Transportation/Ambulance
|
YES | Tier 1: $200.00 Tier 2: $200.00 |
$200.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Provided at Capital Health Plan's Eye Care Centers |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
|
YES | Tier 1: $15.00 Tier 2: $15.00 |
100.00% |
| Habilitation Services
Limit: 35.0 Visit(s) per Benefit Period Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | Tier 1: $50.00 Tier 2: $50.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 20.0 Days per Benefit Period |
YES | Tier 1: $35.00 Tier 2: $35.00 |
100.00% |
| Hospice Services
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | Tier 1: $250.00 Tier 2: $250.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
NO | ||
| Inpatient Hospital Services (e.g., Hospital Stay)
per day up to 5 days |
YES | Tier 1: $750.00 Copay per Day Tier 2: $750.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
per day up to 5 days |
YES | Tier 1: $750.00 Tier 2: $750.00 |
100.00% |
| Mental/Behavioral Health Outpatient Services
Non-Office Mental Health visit cost share will align with Outpatient Facility Fee cost share |
YES | Tier 1: $50.00 Tier 2: $50.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | Tier 1: $60.00 Tier 2: $60.00 |
100.00% |
| Nutritional Counseling
Diabetes coverage includes 'nutrition counseling'; home health services include 'nutritional guidance.' |
YES | Tier 1: $50.00 Tier 2: $50.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | Tier 1: $25.00 Tier 2: $25.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | Tier 1: $350.00 Tier 2: $750.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | Tier 1: $50.00 Tier 2: $50.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | Tier 1: $100.00 Tier 2: $100.00 |
100.00% |
| Preferred Brand Drugs
|
YES | Tier 1: $30.00 Tier 2: $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | Tier 1: $50.00 Tier 2: $50.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | Tier 1: $25.00 Tier 2: $25.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Radiation
|
YES | Tier 1: $750.00 Tier 2: $750.00 |
100.00% |
| Reconstructive Surgery
Only for Breast reconstruction following a Mastectomy. |
YES | Tier 1: $750.00 Tier 2: $750.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | Tier 1: $50.00 Tier 2: $50.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | Tier 1: $50.00 Tier 2: $50.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year Provided at Capital Health Plan's Eye Care Centers |
YES | Tier 1: $50.00 Tier 2: $50.00 |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Provided at Capital Health Plan's Eye Care Centers |
YES | Tier 1: $50.00 Tier 2: $50.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Specialist Visit
|
YES | Tier 1: $50.00 Tier 2: $50.00 |
100.00% |
| Specialty Drugs
|
YES | Tier 1: $250.00 Tier 2: $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
per day up to 5 days |
YES | Tier 1: $750.00 Tier 2: $750.00 |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | Tier 1: $50.00 Tier 2: $50.00 |
100.00% |
| Transplant
|
YES | Tier 1: $750.00 Tier 2: $750.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | Tier 1: $750.00 Tier 2: $750.00 |
100.00% |
| Urgent Care Centers or Facilities
|
YES | Tier 1: $50.00 Tier 2: $50.00 |
$50.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
Capital Health Plan HMO Gold 3000 (Wellness Program $$$) Health Insurance Plan Variant 66966FL0050003-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.812721350104386 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes |
| EHB Percent of Total Premium | 0.9988 |
| First Tier Utilization | 4% |
| Formulary ID | FLF006 |
| Formulary URL | URL |
| HIOS Product ID | 66966FL005 |
| Import Date | 2024-10-17 01:02:25 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 5 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 66966 |
| Issuer Marketplace Marketing Name | Capital Health Plan |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | FLN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Care |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Urgent and Emergency Care |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 66966FL0050003-01 |
| Plan Marketing Name | Capital Health Plan HMO Gold 3000 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Capital Health Plan HMO Gold 3000 (Wellness Program $$$) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $800 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $600 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 96% |
| Service Area ID | FLS001 |
| Source Name | HIOS |
| Plan ID | 66966FL0050003 |
| State Code | FL |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $15800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $7900 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $7,900 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $15800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7900 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,900 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $15800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $7900 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $7,900 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Capital Health Plan HMO Gold 3000 Health Insurance Plan, 66966FL0050003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Capital Health Plan HMO Gold 3000, 66966FL0050003 Health Insurance Plan, 66966FL0050003
-
Does Capital Health Plan HMO Gold 3000 Health Insurance Plan, 66966FL0050003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (66966FL0050003) Health Insurance Plan, Variant (66966FL0050003-01) offer Disease Management Programs?
Does (66966FL0050003) Health Insurance Plan, Variant (66966FL0050003-01) have Out Of Country Coverage?
Does (66966FL0050003) Health Insurance Plan, Variant (66966FL0050003-01) have Out of Service Area Coverage?
Does (66966FL0050003) Health Insurance Plan, Variant (66966FL0050003-01) offer Disease Management Programs?
Does Capital Health Plan HMO Gold 3000 (Wellness Program $$$) Health Insurance Plan, Variant (66966FL0050003-01) offer Disease Management Programs for Asthma?
Does Capital Health Plan HMO Gold 3000 (Wellness Program $$$) Health Insurance Plan, Variant (66966FL0050003-01) offer Disease Management Programs for Heart disease?
Does Capital Health Plan HMO Gold 3000 (Wellness Program $$$) Health Insurance Plan, Variant (66966FL0050003-01) offer Disease Management Programs for Depression?
Does Capital Health Plan HMO Gold 3000 (Wellness Program $$$) Health Insurance Plan, Variant (66966FL0050003-01) offer Disease Management Programs for Diabetes?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API