CommunityCare Gold L21 Select Plus - 98905OK0130041 Health Insurance Plan
CommunityCare HMO Inc. health insurance plan with the Plan ID 98905OK0130041. The plan is called CommunityCare Gold L21 Select Plus.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.01% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.99% 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 77.97% (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 22.03% 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 | 98905OK0130041 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Oklahoma | ||||||||||||||||||
| Health Insurance Issuer | CommunityCare HMO Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 98905OK0130041-03 | ||||||||||||||||||
| Provider Network(s) | PREFFERED | ||||||||||||||||||
| 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 - 98905OK0130041-00 Standard On Exchange Plan - 98905OK0130041-01 |
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| Last Plan Update Date | Tue, 19 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of CommunityCare Gold L21 Select Plus Health Insurance Plan, 98905OK0130041-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: Abortions are excluded, except as allowed by law to protect the life of the mother from imminent danger |
NO | ||
| Accidental Dental
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Exclusions: Except when medically necessary |
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
|
YES | $50.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | $50.00 Copay after deductible |
$50.00 Copay after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year 1 pair of standard lenses and frames or contacts per year |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
|
YES | $10.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year Up to 60 treatment days per disability, per calendar year. Combination of Physical Therapy, Occupational Therapy and Speech Therapy. |
YES | 20.00% |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 2 Years 1 hearing aid per ear every 48 months |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Must be medically necessary and is subject to prior authorization |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Must be medically necessary and is subject to prior authorization |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 20.00% |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $95.00 Copay after deductible |
100.00% |
| Nutritional Counseling
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Up to 60 treatment days per disability, per calendar year. Combination of Physical Therapy, Occupational Therapy and Speech Therapy. |
YES | 20.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $45.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
| Private-Duty Nursing
Limit: 85.0 Visit(s) per Year |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Radiation
Must be medically necessary and is subject to prior authorization |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: Surgery performed primarily to improve or alter the Member's external appearance is excluded Covered in cases of mastectomies and medically necessary situations, and for medically necessary reconstructive surgery due to accidental injury, functional congenital defects, or deformities that are the result of treatment or illness that substantially impair bodily function. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Year Up to 60 treatment days per disability, per calendar year. Combination of Physical Therapy, Occupational Therapy and Speech Therapy. |
YES | 20.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Year Up to 60 treatment days per disability, per calendar year. Combination of Physical Therapy, Occupational Therapy and Speech Therapy. |
YES | 20.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Visit(s) per Year Up to 60 treatment days per disability, per calendar year |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $50.00 |
100.00% |
| Specialty Drugs
|
YES | $300.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Transplant
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $50.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 20.00% |
100.00% |
CommunityCare Gold L21 Select Plus Health Insurance Plan Variant 98905OK0130041-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7797039965030781 |
| 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 | Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pain Management |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | OKF004 |
| Formulary URL | URL |
| HIOS Product ID | 98905OK013 |
| Import Date | 2023-12-19 01:01:03 |
| 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 Actuarial Value | 78.01% |
| Issuer ID | 98905 |
| Issuer Marketplace Marketing Name | CommunityCare |
| 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 | OKN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 98905OK0130041-03 |
| Plan Marketing Name | CommunityCare Gold L21 Select Plus |
| Plan Type | HMO |
| Plan Variant Marketing Name | CommunityCare Gold L21 Select Plus |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,700 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $4,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $90 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $90 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,300 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OKS001 |
| Source Name | HIOS |
| Plan ID | 98905OK0130041 |
| State Code | OK |
| 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 | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $12000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,000 |
| 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 | $17100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8300 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,300 |
| 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 | Yes |
Copay & Coinsurance of CommunityCare Gold L21 Select Plus Health Insurance Plan, 98905OK0130041
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about CommunityCare Gold L21 Select Plus, 98905OK0130041 Health Insurance Plan, 98905OK0130041
-
Does CommunityCare Gold L21 Select Plus Health Insurance Plan, 98905OK0130041 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (98905OK0130041) Health Insurance Plan, Variant (98905OK0130041-03) offer Disease Management Programs?
Does (98905OK0130041) Health Insurance Plan, Variant (98905OK0130041-03) have Out Of Country Coverage?
Does (98905OK0130041) Health Insurance Plan, Variant (98905OK0130041-03) have Out of Service Area Coverage?
Does (98905OK0130041) Health Insurance Plan, Variant (98905OK0130041-03) offer Disease Management Programs?
Does CommunityCare Gold L21 Select Plus Health Insurance Plan, Variant (98905OK0130041-03) offer Disease Management Programs for Heart disease?
Does CommunityCare Gold L21 Select Plus Health Insurance Plan, Variant (98905OK0130041-03) offer Disease Management Programs for Diabetes?
Does CommunityCare Gold L21 Select Plus Health Insurance Plan, Variant (98905OK0130041-03) offer Disease Management Programs for High blood pressure & high cholesterol?
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