Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision - 58840TX0110147 Health Insurance Plan
Aetna Health Inc. (a TX corp.) health insurance plan with the Plan ID 58840TX0110147. The plan is called Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.99% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.01% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 58840TX0110147 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | Aetna Health Inc. (a TX corp.) | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 58840TX0110147-00 | ||||||||||||||||||
| 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 - 58840TX0110147-00 Standard On Exchange Plan - 58840TX0110147-01 |
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| Last Plan Update Date | Wed, 02 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision Health Insurance Plan, 58840TX0110147-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Member cost share based on place and type of service. |
YES | $25.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Member cost share based on place and type of service. |
YES | $25.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
Coverage is limited to ages 19 and up.?$50 deductible / $1,000 calendar year maximum for all dental services (Routine check-up, Basic & Major). |
YES | 50.00% |
100.00% |
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Member cost share based on place and type of service. |
YES | 50.00% |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year Coverage is limited to 35 visits per year for Physical Therapy, Occupational Therapy, and Chiropractic Care combined. |
YES | $25.00 |
100.00% |
| Cosmetic Surgery
Covered only to correct conditions resulting from an accidental injury, gross anatomical defect present at birth or needed for the treatment of an illness.Copay per day for days 1-5 |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Copay per day for days 1-5 |
YES | $1,000.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Member cost share based on place and type of service. |
YES | $25.00 |
100.00% |
| Dialysis
Member cost share based on place and type of service. |
YES | $600.00 |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% |
100.00% |
| Emergency Room Services
Exclusions: No coverage for non-emergency use of the emergency room. |
YES | $750.00 |
$750.00 |
| Emergency Transportation/Ambulance
|
YES | $750.00 |
$750.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per year, through the end of the month in which the member turns 19. |
YES | $10.00 |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | $3.00 |
100.00% |
| Habilitation Services
Health care services that are needed to keep, learn, or improve your skills and functioning for daily living which may include physical therapy, occupational therapy, and speech therapy. Please refer to the plan policy documents for detailed information. |
YES | No Charge |
100.00% |
| Hearing Aids
|
YES | 50.00% |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | $25.00 |
100.00% |
| Hospice Services
Member cost share based on place and type of service.Copay per day for days 1-5 |
YES | $1,000.00 |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $550.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Member cost share based on place and type of service. |
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Copay per day for days 1-5 |
YES | $1000.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $20.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
Coverage is limited to ages 19 and up. 6 month waiting period regardless of prior coverage. $50 deductible / $1,000 calendar year maximum for all dental services (Routine check-up, Basic & Major). |
YES | 50.00% |
100.00% |
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Copay per day for days 1-5 |
YES | $1000.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | No Charge |
100.00% |
| Non-Preferred Brand Drugs
Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Certain nutritional and diet counseling services are available to aid in weight reduction due to obesity, diabetes self management training, autism benefits, and for adults at higher risk of chronic disease. |
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Cost share applies to both in-person and virtual services from in-network providers. Cost share does not apply to virtual services from designated telemedicine providers. If this is an HSA plan, deductible applies. |
YES | No Charge |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $600.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Coverage is limited to 35 visits per year Physical Therapy, Occupational Therapy, Speech Therapy, and Chiropractic combined. Benefit limits are separate for rehabilitation and habilitation services. |
YES | $25.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $250.00 |
100.00% |
| Preferred Brand Drugs
Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | $35.00 |
100.00% |
| Prenatal and Postnatal Care
Member cost sharing applies to postnatal care. |
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Age and frequency schedules may apply. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Cost share applies to both in-person and virtual services from in-network providers. Cost share does not apply to virtual services from designated telemedicine providers. |
YES | No Charge |
100.00% |
| Private-Duty Nursing
Covered when medically necessary during an inpatient stay.Copay per day for days 1-5 |
YES | $1,000.00 |
100.00% |
| Prosthetic Devices
|
YES | 50.00% |
100.00% |
| Radiation
Member cost share based on place and type of service. |
YES | 50.00% |
100.00% |
| Reconstructive Surgery
Member cost share based on place and type of service.Copay per day for days 1-5 |
YES | $1,000.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Year Coverage is limited to 35 visits per year Physical Therapy, Occupational Therapy, Speech Therapy, and Chiropractic combined. Benefit limits are separate for rehabilitation and habilitation services. |
YES | $25.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Year Coverage is limited to 35 visits per year Physical Therapy, Occupational Therapy, Speech Therapy, and Chiropractic combined. Benefit limits are separate for rehabilitation and habilitation services. |
YES | $25.00 |
100.00% |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year Coverage is limited to ages 19 and up. $1,000 calendar year maximum for all dental services (Routine check-up, Basic & Major). |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year Coverage is limited to ages 19 and up. Benefit limitations may apply. |
YES | $10.00 |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Coverage is limited to 1 exam every 12 months through the end of the month in which the member turns 19. |
YES | $10.00 |
100.00% |
| Routine Foot Care
Foot care for diabetics is covered. |
NO | ||
| Skilled Nursing Facility
Limit: 25.0 Days per Year Copay per day for days 1-5 |
YES | $1000.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $25.00 |
100.00% |
| Specialty Drugs
Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Copay per day for days 1-5 |
YES | $1000.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge |
100.00% |
| Transplant
Member cost share based on place and type of service. Network benefits must be received within the Institutes of Excellence (IOE) transplant network.Copay per day for days 1-5 |
YES | $1,000.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: Excludes any non-surgical or non-diagnostic services or supplies. Member cost share based on place and type of service. |
YES | $25.00 |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: No coverage for non-urgent care. |
YES | $25.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Age and frequency schedules may apply. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $35.00 |
100.00% |
Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision Health Insurance Plan Variant 58840TX0110147-00 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 | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $500 per group |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $250 per person |
| Drug EHB Deductible, Combined In/Out of Network, Individual | $250 |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $500 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $250 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $250 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| 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 | 0.9553 |
| First Tier Utilization | 100% |
| Formulary ID | TXF012 |
| Formulary URL | URL |
| HIOS Product ID | 58840TX011 |
| Import Date | 2024-10-02 01:01:28 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | 0 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 81.99% |
| Issuer ID | 58840 |
| Issuer Marketplace Marketing Name | Aetna CVS Health |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | TXN009 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Except for Emergencies |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 58840TX0110147-00 |
| Plan Marketing Name | Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $2,200 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TXS009 |
| Source Name | HIOS |
| Specialist Requiring a Referral | Referral required for all physicians EXCEPT OB/GYN, ER, Internal Medicine, Family Practice, General Medicine and Pediatrician. |
| Plan ID | 58840TX0110147 |
| State Code | TX |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $13190 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $6595 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $6,595 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $13190 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6595 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,595 |
| 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 Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision Health Insurance Plan, 58840TX0110147
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision, 58840TX0110147 Health Insurance Plan, 58840TX0110147
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Does Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision Health Insurance Plan, 58840TX0110147 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (58840TX0110147) Health Insurance Plan, Variant (58840TX0110147-00) offer Disease Management Programs?
Does (58840TX0110147) Health Insurance Plan, Variant (58840TX0110147-00) have Out Of Country Coverage?
Does (58840TX0110147) Health Insurance Plan, Variant (58840TX0110147-00) have Out of Service Area Coverage?
Does (58840TX0110147) Health Insurance Plan, Variant (58840TX0110147-00) offer Disease Management Programs?
Does Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision Health Insurance Plan, Variant (58840TX0110147-00) offer Disease Management Programs for Asthma?
Does Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision Health Insurance Plan, Variant (58840TX0110147-00) offer Disease Management Programs for Heart disease?
Does Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision Health Insurance Plan, Variant (58840TX0110147-00) offer Disease Management Programs for Depression?
Does Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision Health Insurance Plan, Variant (58840TX0110147-00) offer Disease Management Programs for Diabetes?
Does Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision Health Insurance Plan, Variant (58840TX0110147-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision Health Insurance Plan, Variant (58840TX0110147-00) offer Disease Management Programs for Low back pain?
Does Gold 10 Advanced: $0 PCP + Aetna network + $0 walk-in clinic + Adult Dental + Vision Health Insurance Plan, Variant (58840TX0110147-00) 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