Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 - 61671NC0100007 Health Insurance Plan
Aetna Health Inc. (a PA corp.) health insurance plan with the Plan ID 61671NC0100007. The plan is called Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.02% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.98% 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 78.02% (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 21.98% 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 | 61671NC0100007 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | North Carolina | ||||||||||||||||||
| Health Insurance Issuer | Aetna Health Inc. (a PA corp.) | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 61671NC0100007-03 | ||||||||||||||||||
| 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 - 61671NC0100007-00 Standard On Exchange Plan - 61671NC0100007-01 |
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| Last Plan Update Date | Thu, 21 Sep 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 61671NC0100007-03
| 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 | $60.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Bariatric Surgery
Pre-certification is required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Coverage is limited to 30 visits per calendar year PT, OT and Chiro combined, separate from habilitation and includes all outpatient places of service for PT, OT, and Chiro |
YES | $30.00 |
100.00% |
| Clinical Trials
Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Congenital Anomaly, including Cleft Lip/Palate
Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Anesthesia
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Diabetes Education
Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Dialysis
Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Exclusions: Appliances and accessories that serve no medical purpose or that are primarily for comfort or convenience; repair or replacement of equipment due to abuse or desire for new equipment. Orthotic devices for correction of POSITIONAL PLAGIOCEPHALY are limited to 1 device per lifetime. |
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 Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per year. Age 0-19. |
YES | $10.00 |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $15.00 |
100.00% |
| Habilitation Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Coverage is limited to 1 item per hearing impaired ear every 36 months. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
|
YES | $30.00 |
100.00% |
| Hospice Services
Exclusions: Excludes homemaker services, such as cooking, housekeeping, and food or meal preparation. Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
Member cost share based on place and type of service. |
YES | 25.00% 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 | 25.00% Coinsurance 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
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $30.00 |
100.00% |
| Mental Health Other
Member cost share based on place and type of service. |
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $60.00 |
100.00% |
| Nutritional Counseling
Nutritional counseling visits are separate from the obesity-related office visits. |
YES | No Charge |
100.00% |
| Off Label Prescription Drugs
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $60.00 |
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 | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Coverage is limited to 30 visits per calendar year, PT/OT/Chiro combined, separate from habilitation. |
YES | $30.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
Member cost sharing applies to postnatal care |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Age and frequency schedules may apply. |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
| Private-Duty Nursing
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Exclusions: Dental appliances except when medically necessary for the treatment of temporomandibular joint disease or obstructive sleep apnea; cosmetic improvements, such as implants of hair follicles and skin tone enhancements; lenses for keratoconus or any other eye procedure except as specifically covered under the health plan. Prosthetic appliance must replace all or part of a body |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
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: 30.0 Visit(s) per Year Coverage is limited to 30 visits per calendar year, PT/OT/Chiro combined, separate from habilitation. |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Coverage is limited to 30 visits per calendar year,, separate from habilitation. |
YES | $30.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Coverage is limited to 1 exam every 12 months. |
YES | $10.00 |
100.00% |
| Routine Foot Care
Coverage is limited to the treatment of corns, calluses and care of the toenails for patients with diabetes or vascular disease and treatment of bunions (capsular or bone surgery). Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Skilled Nursing Facility
Limit: 90.0 Days per Year Coverage is limited to 90 days per calendar year. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
100.00% |
| Transplant
Exclusions: The purchase price of organs or tissue if any organ or tissue is sold rather than donated to the recipient member; the procurement of organs, tissue, bone marrow, or peripheral blood stem cells or any other donor services if a recipient is not a member; transplants, including high dose chemotherapy, considered experimental or investigational; services for or related to the transplantation of animal or artificial organs or tissues.. Benefits are provided for reasonable and necessary |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: Excludes Treatment for periodontal disease; Dental implants or root canals; Crowns and bridges; Orthodontic brace; Occlusal (bite) adjustments; Extractions. Therapeutic benefits for TMJ disease include splinting |
YES | $60.00 |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: No coverage for non-urgent care. |
YES | $45.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
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 every 12 months thereafter to age 22. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: Lab tests that are not ordered by a Doctor or Other Provider. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan Variant 61671NC0100007-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7802 |
| 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 | Design 1 |
| 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 | NCF010 |
| Formulary URL | URL |
| HIOS Product ID | 61671NC010 |
| Import Date | 2023-09-21 01:01:38 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | 0 |
| 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 | 78.02% |
| Issuer ID | 61671 |
| 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 | NCN001 |
| 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) | 61671NC0100007-03 |
| Plan Marketing Name | Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,500 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,200 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NCS001 |
| Source Name | HIOS |
| Plan ID | 61671NC0100007 |
| State Code | NC |
| 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 | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| 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 | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| 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 S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 61671NC0100007
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7, 61671NC0100007 Health Insurance Plan, 61671NC0100007
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Does Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 61671NC0100007 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (61671NC0100007) Health Insurance Plan, Variant (61671NC0100007-03) offer Disease Management Programs?
Does (61671NC0100007) Health Insurance Plan, Variant (61671NC0100007-03) have Out Of Country Coverage?
Does (61671NC0100007) Health Insurance Plan, Variant (61671NC0100007-03) have Out of Service Area Coverage?
Does (61671NC0100007) Health Insurance Plan, Variant (61671NC0100007-03) offer Disease Management Programs?
Does Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (61671NC0100007-03) offer Disease Management Programs for Asthma?
Does Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (61671NC0100007-03) offer Disease Management Programs for Heart disease?
Does Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (61671NC0100007-03) offer Disease Management Programs for Depression?
Does Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (61671NC0100007-03) offer Disease Management Programs for Diabetes?
Does Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (61671NC0100007-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (61671NC0100007-03) offer Disease Management Programs for Low back pain?
Does Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (61671NC0100007-03) 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