Community Select Gold 022 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth) - 27248TX0010022 Health Insurance Plan
Community Health Choice, Inc. health insurance plan with the Plan ID 27248TX0010022. The plan is called Community Select Gold 022 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.13% (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 21.87% 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 | 27248TX0010022 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | Community Health Choice, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 27248TX0010022-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED NON-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 - 27248TX0010022-00 Standard On Exchange Plan - 27248TX0010022-01 |
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| Last Plan Update Date | Wed, 08 Nov 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Community Select Gold 022 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth) Health Insurance Plan, 27248TX0010022-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Cost sharing and limitation depend on type and site of service. Limited to treatment for a Dental Injury to a Sound Natural Tooth. |
YES | $30.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Cost sharing depends on type and site of service. |
YES | $30.00 Copay after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Cost sharing and limitation depend on type and site of service. Injectable chemotherapeutic agents require preauthorization. |
YES | $30.00 Copay after deductible |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
YES | $30.00 Copay after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Cost sharing depends on type and site of service. |
YES | $15.00 Copay after deductible |
100.00% |
| Dialysis
Cost sharing depends on type and site of service. |
YES | $30.00 Copay after deductible |
100.00% |
| Durable Medical Equipment
Certain services require preauthorization (DME over $500). |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Exclusions: Travel or ambulance services for convenience. Prior authorization required for out of network ambulance services, out of area transfers, non-emergency ground transportation, air transportation, and facility to facility transfers. |
YES | $30.00 Copay after deductible |
$30.00 Copay after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year For select frames, standard lenses, and contact lenses only. |
YES | $30.00 Copay after deductible |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Subject to formulary requirements and preauthorization may be required (when generic is not the preferred agent). |
YES | $10.00 |
100.00% |
| Habilitation Services
Cost sharing depends on type and site of service. Limited to medical necessity. Prior authorization is required. |
YES | $30.00 Copay after deductible |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years To restore or correction of impaired speech or hearing loss. Each ear, every three years. Prior authorization is required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Prior Authorization is required. |
YES | $30.00 Copay after deductible |
100.00% |
| Hospice Services
Cost sharing and limitations depend on type and site of service. |
YES | $30.00 Copay after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Preauthorization is required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Cost sharing and limitation depend on type and site of service. Preauthorization is required. |
YES | $30.00 Copay after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Prior Authorization is required for inpatient surgical services. |
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Some services require preauthorization. |
YES | $15.00 Copay after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Preauthorization is required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Certain services require preauthorization.Cost sharing depends on type and site of service. This benefit (Mental/Behavioral Health Outpatient Services, Substance Abuse Disorder Outpatient Services, and Habilitation Services) is subject to different cost-sharing depending on whether the service is an office visit or other outpatient service. Office visits are subject to copays, while facility-based services are subject to coinsurance. |
YES | $15.00 |
100.00% |
| Non-Preferred Brand Drugs
Subject to formulary requirements and preauthorization may be required. |
YES | $100.00 Copay after deductible |
100.00% |
| Nutritional Counseling
Preauthorization is required. Cost sharing depends on type and site of service. |
YES | $15.00 Copay after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Cost sharing and limitations depend on type and site of service. |
YES | $15.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Cost sharing and limitations depend on the type and site of service. Preauthorization is required for outpatient surgeries. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limited to Medically Necessary outpatient Rehabilitative Therapy visits to or by a Participating Provider other than a Primary Care Physician. Prior authorization is required. |
YES | $30.00 Copay after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Outpatient services and Habilitation Services are subject to different cost-sharing depending on whether the service is an office visit or other outpatient service. Office visits are subjec to copays, while facility-based services are subject to coinsurance. Preauthorization is required for outpatient surgeries. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Subject to formulary requirements and preauthorization may be required. |
YES | $50.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $30.00 Copay after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $15.00 |
100.00% |
| Private-Duty Nursing
Inpatient private duty nursing. |
YES | $30.00 Copay after deductible |
100.00% |
| Prosthetic Devices
Medically necessary foot orthotics are not subject to a calendar year maximum. Preauthorization is required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Radiation
Cost sharing and limitation depend on type and site of service. Proton beam radiation requires preauthorization. |
YES | $30.00 Copay after deductible |
100.00% |
| Reconstructive Surgery
Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. Preauthorization is required. Cost sharing depends on type and site of service. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Prior Authorization is required. Limited to medical necessity. |
YES | $30.00 Copay after deductible |
100.00% |
| Rehabilitative Speech Therapy
Prior Authorization is required. Limited to medical necessity. |
YES | $30.00 Copay after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Covered services for children 18 and under. |
YES | $30.00 Copay after deductible |
100.00% |
| Routine Foot Care
Coverage for foot care is limited to members with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency is covered. Any services or supplies in connection with routine foot care, including the removal of warts, corns, or calluses, or the cutting and trimming of toenails in the absence of diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency are excluded. Cost sharing and limitations depend on site of service. |
YES | $30.00 Copay after deductible |
100.00% |
| Skilled Nursing Facility
Limit: 25.0 Days per Year Cost sharing and limitation depend on type and site of service. Prior authorization is required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $30.00 |
100.00% |
| Specialty Drugs
Subject to formulary requirements and preauthorization may be required. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Preauthorization is required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Certain services require preauthorization.Cost sharing depends on type and site of service. This benefit (Mental/Behavioral Health Outpatient Services, Substance Abuse Disorder Outpatient Services, and Habilitation Services) is subject to different cost-sharing depending on whether the service is an office visit or other outpatient service. Office visits are subject to copays, while facility-based services are subject to coinsurance. |
YES | $15.00 |
100.00% |
| Transplant
Exclusions: Subject to the conditions described below, benefits for covered services and supplies provided to a Participant by a Hospital, Physician, or Other Provider related to an organ or tissue transplant will be determined as follows, but only if all the following conditions are met: The transplant procedure is not Experimental/Investigational in nature; and Donated human organs or tissue or an FDA-approved artificial device are used; and The recipient is a Participant under the Plan; and The transplant procedure is preauthorized as required under the Plan; and The Participant meets all of the criteria established by CHC in pertinent written medical policies; and The Participant meets all of the protocols established by the Hospital in which the transplant is performed. Donor expenses for a Participant in connection with an organ or tissue transplant is not a covered benefit if the recipient is not covered under this Plan. No benefits are available for any organ or tissue transplant procedure, or services performed in preparation for, or in conjunction with, such procedure, which CHC considers to be Experimental/Investigational. Preauthorization is required. Cost sharing and limitation depend on type and site of service. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Prior authorization required for temporomandibular joint surgery. |
YES | $30.00 |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $30.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Prior Authorization is required. |
YES | $15.00 Copay after deductible |
100.00% |
Community Select Gold 022 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth) Health Insurance Plan Variant 27248TX0010022-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.781277416641088 |
| 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 | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | TXF003 |
| Formulary URL | URL |
| HIOS Product ID | 27248TX001 |
| Import Date | 2023-11-08 01:01:43 |
| 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 | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 27248 |
| Issuer Marketplace Marketing Name | Community Health Choice |
| 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 | TXN003 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | For emergency only |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 27248TX0010022-00 |
| Plan Marketing Name | Community Select Gold 022 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth) |
| Plan Type | HMO |
| Plan Variant Marketing Name | Community Select Gold 022 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,100 |
| SBC Scenario, Having a Baby, Copayment | $300 |
| SBC Scenario, Having a Baby, Deductible | $1,800 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $1,800 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $50 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TXS002 |
| Source Name | HIOS |
| Plan ID | 27248TX0010022 |
| State Code | TX |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $18900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $9450 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $9,450 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $3600 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $1800 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $1,800 |
| 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 | $3600 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1800 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,800 |
| 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 | $18900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9450 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,450 |
| 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 Community Select Gold 022 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth) Health Insurance Plan, 27248TX0010022
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Community Select Gold 022 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth), 27248TX0010022 Health Insurance Plan, 27248TX0010022
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Does Community Select Gold 022 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth) Health Insurance Plan, 27248TX0010022 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (27248TX0010022) Health Insurance Plan, Variant (27248TX0010022-00) offer Disease Management Programs?
Does (27248TX0010022) Health Insurance Plan, Variant (27248TX0010022-00) have Out Of Country Coverage?
Does (27248TX0010022) Health Insurance Plan, Variant (27248TX0010022-00) have Out of Service Area Coverage?
Does (27248TX0010022) Health Insurance Plan, Variant (27248TX0010022-00) offer Disease Management Programs?
Does Community Select Gold 022 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth) Health Insurance Plan, Variant (27248TX0010022-00) offer Disease Management Programs for Asthma?
Does Community Select Gold 022 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth) Health Insurance Plan, Variant (27248TX0010022-00) offer Disease Management Programs for Heart disease?
Does Community Select Gold 022 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth) Health Insurance Plan, Variant (27248TX0010022-00) offer Disease Management Programs for Diabetes?
Does Community Select Gold 022 (No Deductible for PCP, Specialists & Generics, Free 24/7 Telehealth) Health Insurance Plan, Variant (27248TX0010022-00) offer Disease Management Programs for Pregnancy?
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