Everyday Gold + Vision + Adult Dental - 70111TN0120030 Health Insurance Plan
Celtic Insurance Company health insurance plan with the Plan ID 70111TN0120030. The plan is called Everyday Gold + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.31% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.69% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 70111TN0120030 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Tennessee | ||||||||||||||||||
| Health Insurance Issuer | Celtic Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 70111TN0120030-01 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 70111TN0120030-00 Standard On Exchange Plan - 70111TN0120030-01 |
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| Last Plan Update Date | Tue, 19 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Everyday Gold + Vision + Adult Dental Health Insurance Plan, 70111TN0120030-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $55.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
100.00% |
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year |
YES | $55.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $55.00 |
100.00% |
| Dialysis
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
| Eye Glasses for Adults
|
NO | ||
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Cost sharing shown applies to Tier 2-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 3-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information. |
YES | $3.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year Limited to 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy); Limited to 36 visits per year per therapy for cardiac and pulmonary therapy. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Limit: 2.0 Item(s) per 3 Years Limited to 1 item per ear every 3 years. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Respite care covered in conjunction with hospice services. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 35.00% Coinsurance 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 | 35.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $35.00 |
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
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
100.00% |
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Emergency Room
|
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
| Mental/Behavioral Health Emergency Transportation/Ambulance
|
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
| Mental/Behavioral Health ER Physician Fee
|
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
| Mental/Behavioral Health Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. |
YES | $35.00 |
100.00% |
| Mental/Behavioral Health Urgent Care
|
YES | $35.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | $55.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $35.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Limited to 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy); Limited to 36 visits per year per therapy for cardiac and pulmonary therapy. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $60.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $35.00 |
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 24/7 Care Visits received from Ambetter?s designated telehealth provider covered at No Charge, except for HSAs. |
YES | $35.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality... 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required - please contact the number listed on your ID card. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Limited to 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy); Limited to 36 visits per year per therapy for cardiac and pulmonary therapy. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Limited to 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy); Limited to 36 visits per year per therapy for cardiac and pulmonary therapy. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eye glasses. |
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
|
YES | $55.00 |
100.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $55.00 |
100.00% |
| Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. |
YES | $35.00 |
100.00% |
| Substance Use Disorder Emergency Room
|
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
| Substance Use Disorder Emergency Transportation/Ambulance
|
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
| Substance Use Disorder ER Physician Fee
|
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
| Substance Use Disorder Outpatient Other Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Substance Use Disorder Urgent Care
|
YES | $35.00 |
100.00% |
| Tier 3 Generic Drugs
Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information. |
YES | $15.00 |
100.00% |
| Transplant
Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $35.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Covered in accordance with ACA guidelines. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Everyday Gold + Vision + Adult Dental Health Insurance Plan Variant 70111TN0120030-01 Attributes
| Plan Attribute | Value |
|---|---|
| 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 On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 0.966 |
| First Tier Utilization | 100% |
| Formulary ID | TNF009 |
| Formulary URL | URL |
| HIOS Product ID | 70111TN012 |
| 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 | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 78.31% |
| Issuer ID | 70111 |
| Issuer Marketplace Marketing Name | Ambetter of Tennessee |
| 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 | TNN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 70111TN0120030-01 |
| Plan Marketing Name | Everyday Gold + Vision + Adult Dental |
| Plan Type | EPO |
| Plan Variant Marketing Name | Everyday Gold + Vision + Adult Dental |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,800 |
| SBC Scenario, Having a Baby, Copayment | $500 |
| SBC Scenario, Having a Baby, Deductible | $750 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $10 |
| SBC Scenario, Having Diabetes, Copayment | $1,400 |
| SBC Scenario, Having Diabetes, Deductible | $750 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $750 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TNS001 |
| Source Name | HIOS |
| Plan ID | 70111TN0120030 |
| State Code | TN |
| 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 | 35.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $750 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $750 |
| 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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Everyday Gold + Vision + Adult Dental Health Insurance Plan, 70111TN0120030
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Everyday Gold + Vision + Adult Dental, 70111TN0120030 Health Insurance Plan, 70111TN0120030
-
Does Everyday Gold + Vision + Adult Dental Health Insurance Plan, 70111TN0120030 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (70111TN0120030) Health Insurance Plan, Variant (70111TN0120030-01) offer Disease Management Programs?
Does (70111TN0120030) Health Insurance Plan, Variant (70111TN0120030-01) have Out Of Country Coverage?
Does (70111TN0120030) Health Insurance Plan, Variant (70111TN0120030-01) have Out of Service Area Coverage?
Does (70111TN0120030) Health Insurance Plan, Variant (70111TN0120030-01) offer Disease Management Programs?
Does Everyday Gold + Vision + Adult Dental Health Insurance Plan, Variant (70111TN0120030-01) offer Disease Management Programs for Asthma?
Does Everyday Gold + Vision + Adult Dental Health Insurance Plan, Variant (70111TN0120030-01) offer Disease Management Programs for Heart disease?
Does Everyday Gold + Vision + Adult Dental Health Insurance Plan, Variant (70111TN0120030-01) offer Disease Management Programs for Diabetes?
Does Everyday Gold + Vision + Adult Dental Health Insurance Plan, Variant (70111TN0120030-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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