Gym Access IND Gold HMO 4500 - 56503FL2090002 Health Insurance Plan
Florida Health Care Plan, Inc. health insurance plan with the Plan ID 56503FL2090002. The plan is called Gym Access IND Gold HMO 4500.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.97% (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 19.03% 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 | 56503FL2090002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Florida | ||||||||||||||||||
| Health Insurance Issuer | Florida Health Care Plan, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 56503FL2090002-03 | ||||||||||||||||||
| Provider Network(s) | 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 - 56503FL2090002-00 Standard On Exchange Plan - 56503FL2090002-01 |
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| Last Plan Update Date | Wed, 03 Jul 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Gym Access IND Gold HMO 4500 Health Insurance Plan, 56503FL2090002-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $35.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Bone Marrow Transplant
Exclusions: Prior authorization is required. Prior authorization is required. Cost sharing is a per day limit. |
YES | $250.00 |
100.00% |
| Chemotherapy
Exclusions: Prior authorization is required. Prior authorization is required. |
YES | 50.00% |
100.00% |
| Chiropractic Care
Limit: 26.0 Visit(s) per Benefit Period |
YES | $35.00 |
100.00% |
| Congenital Anomaly, including Cleft Lip/Palate
Exclusions: Prior authorization is required. Prior authorization is required. |
YES | $35.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: Pre-certification/pre-authorization of coverage required for non-emergency admissions. Pre-certification/pre-authorization of coverage required for non-emergency admissions. Cost sharing is a per day limit, refer to Summary of Benefits and Coverage (SBC) for day limitation. |
YES | $250.00 |
100.00% |
| Dental Anesthesia
Exclusions: Prior authorization is required. Prior authorization is required. |
YES | 10.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
Limit: 50.0 Item(s) per Month Exclusions: In order for services to be covered, diabetes outpatient self-management training and educational services must be provided under the direct supervision of an FHCP certified Diabetes Educator or board-certified Physician spcializing in endocrinology. Additionally, nutrition counseling must be provided by a licensed FHCP contracted dietitian. Includes all medically appropriate and necessary insulin, equipment and supplies, when used to treat diabetes, if the Member's Primary Care Physician, or a Contracting Specialist who specializes in the treatment of diabetes, certifies that such services are necessary. |
YES | $10.00 |
100.00% |
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | 50.00% |
100.00% |
| Durable Medical Equipment
Prior authorization is required. |
YES | 10.00% |
100.00% |
| Emergency Room Services
|
YES | 10.00% Coinsurance after deductible |
10.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 10.00% Coinsurance after deductible |
10.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | $25.00 |
100.00% |
| Gender Affirming Care
Exclusions: Includes sexual re-assignment procedures. Cosmetic procedures and/or complications from such procedure(s) are not covered and are excluded under the plan. Hormone therapy and psychological/behavioral health therapies are covered under their respective benefits. Prior authorization is required. Cost sharing is a per day limit. |
YES | $250.00 |
100.00% |
| Generic Drugs
Limit: 31.0 Days per Benefit Period Exclusions: Available at Preferred-FHCP and select Non-Preferred Retail Pharmacies Only. Available at Preferred-FHCP and select Non-Preferred Retail Pharmacies Only. Up to 93-day Mail Order available through FHCP Only. Refer to the schedule of benefits for cost sharing at Non-Preferred Pharmacies. |
YES | $10.00 |
100.00% |
| Habilitation Services
Limit: 35.0 Visit(s) per Benefit Period Includes Physical Therapy, Speech Therapy and Occupational Therapy. |
YES | $35.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 20.0 Days per Benefit Period Exclusions: Prior authorization is required. Prior authorization is required. |
YES | 10.00% |
100.00% |
| Hospice Services
|
YES | 10.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Prior authorization is required. Tests in hospitals, or facilities owned and operated by hospitals, may have higher cost share. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Exclusions: Prior authorization is required. Prior authorization is required. |
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: Pre-certification/pre-authorization of coverage required for non-emergency admissions. Cost sharing is a per day limit. Pre-certification/pre-authorization of coverage required for non-emergency admissions. Cost sharing is a per day limit. |
YES | $250.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
Tests in hospitals, or facilities owned and operated by hospitals, may have higher cost share. |
YES | $25.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: Pre-certification/pre-authorization of coverage required for non-emergency admissions. Cost sharing is a per day limit. Pre-certification/pre-authorization of coverage required for non-emergency admissions. Cost sharing is a per day limit. |
YES | $250.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $35.00 |
100.00% |
| Non-Preferred Brand Drugs
Limit: 31.0 Days per Benefit Period Exclusions: Available at Preferred-FHCP and select Non-Preferred Retail Pharmacies Only. Available at Preferred-FHCP and select Non-Preferred Retail Pharmacies Only. Up to 93-day Mail Order available through FHCP Only. Refer to the schedule of benefits for cost sharing at Non-Preferred Pharmacies. |
YES | $55.00 |
100.00% |
| Nutritional Counseling
Diabetes education coverage includes nutritional counseling; covered as preventive care |
YES | No Charge |
100.00% |
| Nutrition/Formulas
Exclusions: Prior authorization is required. Prior authorization is required. |
YES | 10.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Osteoporosis
|
YES | $35.00 |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: Additional cost share may apply for Allergy Shots, Injections and Infusions. Additional cost share may apply for Allergy Shots, Injections and Infusions. |
YES | $25.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: Prior authorization is required. Prior authorization is required. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Benefit Period Includes Physical Therapy, Speech Therapy and Occupational Therapy. |
YES | $35.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: Prior authorization is required. Prior authorization is required. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Limit: 31.0 Days per Benefit Period Exclusions: Available at Preferred-FHCP and select Non-Preferred Retail Pharmacies Only. Available at Preferred-FHCP and select Non-Preferred Retail Pharmacies Only. Up to 93-day Mail Order available through FHCP Only. Refer to the schedule of benefits for cost sharing at Non-Preferred Pharmacies. |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $35.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: Additional cost share may apply for Allergy Shots, Injections and Infusions. Additional cost share may apply for Allergy Shots, Injections and Infusions. |
YES | $25.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Exclusions: Prior authorization is required. Prior authorization is required. |
YES | 10.00% |
100.00% |
| Radiation
Exclusions: Prior authorization is required. Prior authorization is required. |
YES | 50.00% |
100.00% |
| Reconstructive Surgery
Exclusions: Prior authorization is required. Only for Breast reconstruction following a Mastectomy. Prior authorization is required. Cost sharing is a per day limit. |
YES | $250.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy. Includes Physical Therapy, Speech Therapy and Occupational Therapy. |
YES | $35.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy. Includes Physical Therapy, Speech Therapy and Occupational Therapy. |
YES | $35.00 |
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 | $10.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period Exclusions: Prior authorization is required. Prior authorization is required. |
YES | $50.00 Copay per Day |
100.00% |
| Specialist Visit
Exclusions: Additional cost share may apply for Allergy Shots, Injections and Infusions. Additional cost share may apply for Allergy Shots, Injections and Infusions. |
YES | $35.00 |
100.00% |
| Specialty Drugs
Limit: 31.0 Days per Benefit Period Exclusions: Available at FHCP Pharmacy Only. Mail Order not available Available at FHCP Pharmacy Only. Mail Order not available |
YES | 50.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: Pre-certification/pre-authorization of coverage required for non-emergency admissions. Cost sharing is a per day limit. Pre-certification/pre-authorization of coverage required for non-emergency admissions. Cost sharing is a per day limit. |
YES | $250.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $35.00 |
100.00% |
| Transplant
Exclusions: Prior authorization is required. Cost sharing is a per day limit. Prior authorization is required. Inpatient per day limitation applies. |
YES | $250.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: Prior authorization is required. Prior authorization is required. One splint in a six month period unless a more frequent replacement is determined to be medically necessary. |
YES | $35.00 |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $75.00 |
$75.00 |
| Weight Loss Programs
|
YES | No Charge |
100.00% |
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Tests in hospitals, or facilities owned and operated by hospitals, may have higher cost share. |
YES | 10.00% Coinsurance after deductible |
100.00% |
Gym Access IND Gold HMO 4500 - Limited Health Insurance Plan Variant 56503FL2090002-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.809678539117968 |
| 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 | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | FLF011 |
| Formulary URL | URL |
| HIOS Product ID | 56503FL209 |
| Import Date | 2024-07-03 04:01:58 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 3 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer ID | 56503 |
| Issuer Marketplace Marketing Name | Florida Health Care Plans |
| 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 | FLN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency and Urgent Care Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency and Urgent Care only, unless pre-authorized by Issuer. |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 56503FL2090002-03 |
| Plan Marketing Name | Gym Access IND Gold HMO 4500 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gym Access IND Gold HMO 4500 - Limited |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $900 |
| SBC Scenario, Having a Baby, Deductible | $300 |
| 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 | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | FLS001 |
| Source Name | HIOS |
| Specialist Requiring a Referral | The member's PCP will refer to all specialists, except those listed as "Direct Access" specialists. |
| Plan ID | 56503FL2090002 |
| State Code | FL |
| 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 | 10.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $5100 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2550 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,550 |
| 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 | $10000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,000 |
| 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 | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Gym Access IND Gold HMO 4500 Health Insurance Plan, 56503FL2090002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gym Access IND Gold HMO 4500, 56503FL2090002 Health Insurance Plan, 56503FL2090002
-
Does Gym Access IND Gold HMO 4500 Health Insurance Plan, 56503FL2090002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (56503FL2090002) Health Insurance Plan, Variant (56503FL2090002-03) offer Disease Management Programs?
Does (56503FL2090002) Health Insurance Plan, Variant (56503FL2090002-03) have Out Of Country Coverage?
Does (56503FL2090002) Health Insurance Plan, Variant (56503FL2090002-03) have Out of Service Area Coverage?
Does (56503FL2090002) Health Insurance Plan, Variant (56503FL2090002-03) offer Disease Management Programs?
Does Gym Access IND Gold HMO 4500 - Limited Health Insurance Plan, Variant (56503FL2090002-03) offer Disease Management Programs for Asthma?
Does Gym Access IND Gold HMO 4500 - Limited Health Insurance Plan, Variant (56503FL2090002-03) offer Disease Management Programs for Heart disease?
Does Gym Access IND Gold HMO 4500 - Limited Health Insurance Plan, Variant (56503FL2090002-03) offer Disease Management Programs for Depression?
Does Gym Access IND Gold HMO 4500 - Limited Health Insurance Plan, Variant (56503FL2090002-03) offer Disease Management Programs for Diabetes?
Does Gym Access IND Gold HMO 4500 - Limited Health Insurance Plan, Variant (56503FL2090002-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Gym Access IND Gold HMO 4500 - Limited Health Insurance Plan, Variant (56503FL2090002-03) offer Disease Management Programs for Low back pain?
Does Gym Access IND Gold HMO 4500 - Limited Health Insurance Plan, Variant (56503FL2090002-03) offer Disease Management Programs for Pregnancy?
Does Gym Access IND Gold HMO 4500 - Limited Health Insurance Plan, Variant (56503FL2090002-03) offer Disease Management Programs for Weight loss programs?
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