CareSource Marketplace Diabetes Gold Dental, Vision, & Fitness - 60224GA0020012 Health Insurance Plan
CareSource Georgia Co. health insurance plan with the Plan ID 60224GA0020012. The plan is called CareSource Marketplace Diabetes Gold Dental, Vision, & Fitness.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.89% (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 18.11% 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 | 60224GA0020012 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Georgia | ||||||||||||||||||
| Health Insurance Issuer | CareSource Georgia Co. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 60224GA0020012-03 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 60224GA0020012-00 Standard On Exchange Plan - 60224GA0020012-01 |
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| Last Plan Update Date | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 10 Dec 2024 06:32 GMT |
Benefits of CareSource Marketplace Diabetes Gold Dental, Vision, & Fitness Health Insurance Plan, 60224GA0020012-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Injury as a result of chewing or biting is not considered an accidental injury. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits. |
YES | 15.00% |
100.00% |
| Basic Dental Care - Child
See plan documents for details on benefit limits |
YES | 15.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Refer to Outpatient Rehabilitation Services, Habilitation Services, and Diagnostic Service for Coverage Information |
NO | ||
| Cosmetic Surgery
Cosmetic Procedures do not include coverage for procedures or services that change or improve appearance without significantly improving physiological function, other than those mandated by State or Federal law. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | $500.00 Copay after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Procedure(s) per Year See plan documents for details on benefit limits |
YES | No Charge |
100.00% |
| Diabetes Education
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Emergency room copay or coinsurance is waived if you are admitted to the hospital directly from the Emergency Department. |
YES | $500.00 Copay after deductible |
$500.00 Copay after deductible |
| Emergency Transportation/Ambulance
Ambulance transports must be made to the closest local facility that can provide you with covered services appropriate for your medical condition. |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Limited to one pair of glasses or contact lenses per benefit year. |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Select Diabetic Drugs and Supplies are covered at no charge. Refer to the plan brochure for more information. |
YES | $2.00 |
100.00% |
| Habilitation Services
Limit: 40.0 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, and Spinal Manipulations are limited to a combined 40 visits per Benefit Year Coverage provided for Physical Therapy and Manipulation Therapy performed by a Chiropractor. |
YES | $15.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 120.0 Visit(s) per Year A visit equals at least 2 hours |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Insulin infusion devices. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $500.00 Copay per Stay after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $30.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits. |
YES | 40.00% |
100.00% |
| Major Dental Care - Child
See plan documents for details on benefit limits |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | $500.00 Copay per Stay after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $15.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Limit: 4.0 Visit(s) per Year |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Limited to Medically Necessary Orthodontia. See plan documents for details on benefit limits. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $15.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 40.0 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, and Spinal Manipulations are limited to a combined 40 visits per Benefit Year. Coverage provided for Physical Therapy and Manipulation Therapy performed by a Chiropractor. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $60.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $50.00 |
100.00% |
| Preventive Care/Screening/Immunization
The recommendations by the USPSTF for breast cancer screenings, mammography and preventions issued prior to November 2009 will be considered current. Immunizations covered are those recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC). |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $15.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Manipulation Therapy, and Cognitive Rehabilitation therapy are limited to a combined 40 visits per year |
YES | $15.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 40.0 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Manipulation Therapy, and Cognitive Rehabilitation therapy are limited to a combined 40 visits per year |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year $1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits. |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $50.00 |
100.00% |
| Specialty Drugs
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $500.00 Copay per Stay after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $15.00 |
100.00% |
| Transplant
Limit: 10000.0 Dollars per Procedure Limited to a combined maximum of $10,000 per covered organ transplant. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $30.00 |
$30.00 |
| Weight Loss Programs
Limit: 4.0 Visit(s) per Year Nutritional counseling for the treatment of obesity, which includes morbid obesity. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Well Baby Visits and Care
Care provided for birth through age 5. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Coverage allowed for X-rays and Diagnostic imaging done at a Chiropractic Office |
YES | 30.00% Coinsurance after deductible |
100.00% |
CareSource Marketplace Diabetes Gold Limited Dental, Vision, & Fitness Health Insurance Plan Variant 60224GA0020012-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.8188897658354549 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 0.980880295781914 |
| First Tier Utilization | 100% |
| Formulary ID | GAF007 |
| Formulary URL | URL |
| HIOS Product ID | 60224GA002 |
| Import Date | 2023-08-16 20:01:48 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 60224 |
| Issuer Marketplace Marketing Name | CareSource |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | GAN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services Only |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 60224GA0020012-03 |
| Plan Marketing Name | CareSource Marketplace Diabetes Gold Dental, Vision, & Fitness |
| Plan Type | HMO |
| Plan Variant Marketing Name | CareSource Marketplace Diabetes Gold Limited Dental, Vision, & Fitness |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,300 |
| SBC Scenario, Having a Baby, Copayment | $500 |
| SBC Scenario, Having a Baby, Deductible | $1,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $900 |
| SBC Scenario, Having Diabetes, Copayment | $400 |
| SBC Scenario, Having Diabetes, Deductible | $1,000 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | GAS001 |
| Source Name | SERFF |
| Plan ID | 60224GA0020012 |
| State Code | GA |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $15000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $7500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $7,500 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $2000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $1000 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $1,000 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $2000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,000 |
| 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 | $15000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,500 |
| 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 | Yes |
Copay & Coinsurance of CareSource Marketplace Diabetes Gold Dental, Vision, & Fitness Health Insurance Plan, 60224GA0020012
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about CareSource Marketplace Diabetes Gold Dental, Vision, & Fitness, 60224GA0020012 Health Insurance Plan, 60224GA0020012
-
Does CareSource Marketplace Diabetes Gold Dental, Vision, & Fitness Health Insurance Plan, 60224GA0020012 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (60224GA0020012) Health Insurance Plan, Variant (60224GA0020012-03) offer Disease Management Programs?
Does (60224GA0020012) Health Insurance Plan, Variant (60224GA0020012-03) have Out Of Country Coverage?
Does (60224GA0020012) Health Insurance Plan, Variant (60224GA0020012-03) have Out of Service Area Coverage?
Does (60224GA0020012) Health Insurance Plan, Variant (60224GA0020012-03) offer Disease Management Programs?
Does CareSource Marketplace Diabetes Gold Limited Dental, Vision, & Fitness Health Insurance Plan, Variant (60224GA0020012-03) offer Disease Management Programs for Asthma?
Does CareSource Marketplace Diabetes Gold Limited Dental, Vision, & Fitness Health Insurance Plan, Variant (60224GA0020012-03) offer Disease Management Programs for Heart disease?
Does CareSource Marketplace Diabetes Gold Limited Dental, Vision, & Fitness Health Insurance Plan, Variant (60224GA0020012-03) offer Disease Management Programs for Depression?
Does CareSource Marketplace Diabetes Gold Limited Dental, Vision, & Fitness Health Insurance Plan, Variant (60224GA0020012-03) offer Disease Management Programs for Diabetes?
Does CareSource Marketplace Diabetes Gold Limited Dental, Vision, & Fitness Health Insurance Plan, Variant (60224GA0020012-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does CareSource Marketplace Diabetes Gold Limited Dental, Vision, & Fitness Health Insurance Plan, Variant (60224GA0020012-03) offer Disease Management Programs for Low back pain?
Does CareSource Marketplace Diabetes Gold Limited Dental, Vision, & Fitness Health Insurance Plan, Variant (60224GA0020012-03) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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