Ambetter of Peach State Inc. health insurance plan with the Plan ID 70893GA0060007. The plan is called Clear Wellstar SELECT Silver with Select Providers.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 94.29% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 5.71% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.29% (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 5.71% 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 | 70893GA0060007 | ||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Georgia | ||||||||||||||||||
Health Insurance Issuer | Ambetter of Peach State Inc. | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 70893GA0060007-06 | ||||||||||||||||||
Provider Network(s) | ['GAN002'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 GMT). |
|
||||||||||||||||||
Available Variants of the Health Plan | Standard Off Exchange Plan - 70893GA0060007-00 Standard On Exchange Plan - 70893GA0060007-01 Open to Indians below 300% FPL - 70893GA0060007-02 Open to Indians above 300% FPL - 70893GA0060007-03 73% AV Silver Plan - 70893GA0060007-04 |
||||||||||||||||||
Last Plan Update Date | Tue, 18 Apr 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | No Charge after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | No Charge after deductible |
100.00% |
Autism Spectrum Disorders
|
YES | No Charge after deductible |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Bone Marrow Transplant
|
YES | No Charge after deductible |
100.00% |
Chemotherapy
|
YES | No Charge after deductible |
100.00% |
Chiropractic Care
Limit: 40.0 Visit(s) per Year Limited to a combined maximum of 40 visits per year for speech therapy, physical therapy and occupational therapy. |
YES | No Charge after deductible |
100.00% |
Clinical Trials
|
YES | No Charge after deductible |
100.00% |
Cosmetic Surgery
Limited to reconstruction due to bodily injury, infection or disease and congenital anomaly. |
YES | No Charge after deductible |
100.00% |
Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
100.00% |
Dental Anesthesia
|
YES | No Charge after deductible |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Care Management
|
YES | No Charge after deductible |
100.00% |
Diabetes Education
|
YES | No Charge after deductible |
100.00% |
Dialysis
|
YES | No Charge after deductible |
100.00% |
Durable Medical Equipment
|
YES | No Charge after deductible |
100.00% |
Emergency Room Services
Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | No Charge after deductible |
No Charge after deductible |
Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
Gender Affirming Care
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
Generic Drugs
Most Ambetter Plans offer Preferred Generic Drugs at $5 or less. Please see plan's Summary of Benefits and Coverage (SBC) or policy document for Preferred Generic and Generic prescription drug cost. |
YES | No Charge after deductible |
100.00% |
Habilitation Services
Limit: 40.0 Visit(s) per Year Limited to a combined maximum of 40 visits per year for speech therapy, physical therapy and occupational therapy. |
YES | No Charge after deductible |
100.00% |
Hearing Aids
Coverage is only for Cochlear Implants and Bone Anchored Hearing Aids. |
NO | ||
Heart Transplant
|
YES | No Charge after deductible |
100.00% |
Home Health Care Services
Limit: 120.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
Hospice Services
|
YES | No Charge after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
Cost share is based on place of service. |
YES | No Charge after deductible |
100.00% |
Infertility Treatment
Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). |
NO | ||
Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
Laboratory Outpatient and Professional Services
Cost share is based on place of service. |
YES | No Charge after deductible |
100.00% |
Long-Term/Custodial Nursing Home Care
Long Term Acute Care is a covered benefit. Long Term Nursing Care/ Custodial Care is not a covered benefit. |
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
NO | ||
Mental/Behavioral Health Emergency Room
|
YES | No Charge after deductible |
No Charge after deductible |
Mental/Behavioral Health Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
Mental/Behavioral Health ER Physician Fee
|
YES | No Charge after deductible |
No Charge after deductible |
Mental/Behavioral Health Inpatient Services
|
YES | No Charge after deductible |
100.00% |
Mental/Behavioral Health Outpatient Other Services
|
YES | No Charge after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
|
YES | No Charge after deductible |
100.00% |
Mental/Behavioral Health Urgent Care
|
YES | No Charge after deductible |
100.00% |
Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
Nutritional Counseling
Limit: 4.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
Off Label Prescription Drugs
|
YES | No Charge after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 40.0 Visit(s) per Year Limited to a combined maximum of 40 visits per year for speech therapy, physical therapy and occupational therapy. |
YES | No Charge after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
Prenatal and Postnatal Care
|
YES | No Charge after deductible |
100.00% |
Preventive Care/Screening/Immunization
Covered in accordance with ACA guidelines. |
YES | No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs. |
YES | No Charge after deductible |
100.00% |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
|
YES | No Charge after deductible |
100.00% |
Radiation
|
YES | No Charge after deductible |
100.00% |
Reconstructive Surgery
|
YES | No Charge after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year Limited to a combined maximum of 40 visits per year for chiropractic care, speech therapy, physical therapy and occupational therapy. |
YES | No Charge after deductible |
100.00% |
Rehabilitative Speech Therapy
Limit: 40.0 Visit(s) per Year Limited to a combined maximum of 40 visits per year for chiropractic care, speech therapy, physical therapy and occupational therapy. |
YES | No Charge after deductible |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
Routine Foot Care
Coverage is limited to diabetes care only. |
NO | ||
Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | No Charge after deductible |
100.00% |
Specialist Visit
|
YES | No Charge after deductible |
100.00% |
Specialty Drugs
|
YES | No Charge after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible |
100.00% |
Substance Use Disorder Emergency Room
|
YES | No Charge after deductible |
No Charge after deductible |
Substance Use Disorder Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
Substance Use Disorder ER Physician Fee
|
YES | No Charge after deductible |
No Charge after deductible |
Substance Use Disorder Outpatient Other Services
|
YES | No Charge after deductible |
100.00% |
Substance Use Disorder Urgent Care
|
YES | No Charge after deductible |
100.00% |
Transplant
Limit: 10000.0 Dollars per Procedure Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | No Charge after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
YES | No Charge after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
100.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
Covered in accordance with ACA guidelines. |
YES | No Charge |
100.00% |
Well Child Care
|
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
Cost share is based on place of service. |
YES | No Charge after deductible |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.942916031 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | 94% AV Level Silver Plan |
Dental Only Plan | No |
Design Type | Not Applicable |
Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 100% |
Formulary ID | GAF009 |
Formulary URL | URL |
HIOS Product ID | 70893GA006 |
Import Date | 4/18/2023 4:02 |
Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
Inpatient Copayment Maximum Days | 0 |
HSA Eligible | No |
New/Existing Plan | Existing |
Notice Required for Pregnancy | Yes |
Is a Referral Required for Specialist? | No |
Issuer Actuarial Value | 94.29% |
Issuer ID | 70893 |
Issuer Marketplace Marketing Name | Ambetter from Peach State Health Plan |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Silver |
Multiple In Network Tiers | No |
National Network | No |
Network ID | GAN002 |
Out of Country Coverage | No |
Out of Service Area Coverage | No |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan ID (Standard Component ID with Variant) | 70893GA0060007-06 |
Plan Marketing Name | Clear Wellstar SELECT Silver with Select Providers |
Plan Type | HMO |
Plan Variant Marketing Name | Clear Wellstar SELECT Silver with Select Providers |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $550 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $0 |
SBC Scenario, Having Diabetes, Deductible | $550 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $550 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | GAS002 |
Source Name | HIOS |
Plan ID | 70893GA0060007 |
State Code | GA |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1100 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $550 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $550 |
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 | $1100 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $550 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $550 |
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 | Yes |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
---|
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 20 Aug 2024 06:14 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