Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 - 58840TX0110087 Health Insurance Plan
Aetna Health Inc. (a TX corp.) health insurance plan with the Plan ID 58840TX0110087. The plan is called Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 80.90% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.10% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 58840TX0110087 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| 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 | 58840TX0110087-00 | ||||||||||||||||||
| 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 - 58840TX0110087-00 Standard On Exchange Plan - 58840TX0110087-01 |
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| Last Plan Update Date | Sat, 16 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 Health Insurance Plan, 58840TX0110087-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Exclusions: Member cost share based on place and type of service. |
YES | $10.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Exclusions: Member cost share based on place and type of service. |
YES | $10.00 |
100.00% |
| Autism Spectrum Disorders
Exclusions: Member cost share based on place and type of service. |
YES | No Charge |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Brain Injury
Exclusions: Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
Exclusions: Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year Exclusions: Coverage is limited to 35 visits per calendar year PT/OT/ST/Chiro combined. Benefit limits are separate for rehabilitation and habilitation services. |
YES | $10.00 |
100.00% |
| Cosmetic Surgery
Exclusions: Covered only to correct conditions resulting from an accidental injury, gross anatomical defect present at birth or needed for the treatment of an illness. |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Exclusions: Member cost share based on place and type of service. |
YES | $10.00 |
100.00% |
| Dialysis
Exclusions: Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Exclusions: No coverage for non-emergency use of the emergency room. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per calendar year. |
YES | $10.00 |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | No Charge |
100.00% |
| Habilitation Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Exclusions: Coverage is limited to 60 visits per calendar year |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Exclusions: Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Exclusions: Coverage is limited to services for fertility preservation see plan booklet for details. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
Exclusions: Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inherited Metabolic Disorder - PKU
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | No Charge |
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 | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | No Charge |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Exclusions: 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)
|
YES | No Charge |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Exclusions: Coverage is limited to 35 visits per calendar year PT/OT/ST/Chiro combined. Benefit limits are separate for rehabilitation and habilitation services. |
YES | $10.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $20.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: Member cost sharing applies to postnatal care. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Prescription Drugs Other
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: Age and frequency schedules may apply. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | No Charge |
100.00% |
| Private-Duty Nursing
Exclusions: Covered when medically necessary during an inpatient stay. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
Exclusions: Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Year Exclusions: Coverage is limited to 35 visits per calendar year PT/OT/ST/Chiro combined. Benefit limits are separate for rehabilitation and habilitation services. |
YES | $10.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Year Exclusions: Coverage is limited to 35 visits per calendar year PT/OT/ST/Chiro combined. Benefit limits are separate for rehabilitation and habilitation services. |
YES | $10.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Exclusions: Coverage is limited to 1 exam per 12 months. |
YES | $10.00 |
100.00% |
| Routine Foot Care
Exclusions: Foot care for diabetics is covered. |
NO | ||
| Skilled Nursing Facility
Limit: 25.0 Days per Year Exclusions: Coverage is limited to 25 days per calendar year. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $10.00 |
100.00% |
| Specialty Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge |
100.00% |
| Transplant
Exclusions: Member cost share based on place and type of service. Network benefits must be received within the transplant network. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: Member cost share based on place and type of service. Excludes any non-surgical or non-diagnostic services or supplies. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $10.00 |
100.00% |
| Weight Loss Programs
Exclusions: Online weight loss programs are available. |
NO | ||
| Well Baby Visits and Care
Exclusions: Coverage is limited 7 exams in the first 12 months of life; 3 exams in the second 12 months of life; 3 exams in the third 12 months of life; 1 exam per 12 months thereafter to age 22. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $10.00 |
100.00% |
Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 Health Insurance Plan Variant 58840TX0110087-00 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 | 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, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | TXF178 |
| Formulary URL | URL |
| HIOS Product ID | 58840TX011 |
| Import Date | 2023-12-16 01:02:09 |
| 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 | 80.90% |
| Issuer ID | 58840 |
| Issuer Marketplace Marketing Name | Aetna CVS Health |
| 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 | TXN005 |
| 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 | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 58840TX0110087-00 |
| Plan Marketing Name | Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,600 |
| SBC Scenario, Having a Baby, Copayment | $20 |
| SBC Scenario, Having a Baby, Deductible | $3,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $300 |
| 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 | $50 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,900 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TXS005 |
| 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 | 58840TX0110087 |
| State Code | TX |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $7000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,500 |
| 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 | $18000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,000 |
| 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 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 Health Insurance Plan, 58840TX0110087
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7, 58840TX0110087 Health Insurance Plan, 58840TX0110087
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Does Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 Health Insurance Plan, 58840TX0110087 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (58840TX0110087) Health Insurance Plan, Variant (58840TX0110087-00) offer Disease Management Programs?
Does (58840TX0110087) Health Insurance Plan, Variant (58840TX0110087-00) have Out Of Country Coverage?
Does (58840TX0110087) Health Insurance Plan, Variant (58840TX0110087-00) have Out of Service Area Coverage?
Does (58840TX0110087) Health Insurance Plan, Variant (58840TX0110087-00) offer Disease Management Programs?
Does Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 Health Insurance Plan, Variant (58840TX0110087-00) offer Disease Management Programs for Asthma?
Does Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 Health Insurance Plan, Variant (58840TX0110087-00) offer Disease Management Programs for Heart disease?
Does Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 Health Insurance Plan, Variant (58840TX0110087-00) offer Disease Management Programs for Depression?
Does Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 Health Insurance Plan, Variant (58840TX0110087-00) offer Disease Management Programs for Diabetes?
Does Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 Health Insurance Plan, Variant (58840TX0110087-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 Health Insurance Plan, Variant (58840TX0110087-00) offer Disease Management Programs for Low back pain?
Does Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 Health Insurance Plan, Variant (58840TX0110087-00) 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