KP GA Signature Silver Virtual Complete 5000 - 89942GA0050031 Health Insurance Plan
Kaiser Foundation Health Plan of Georgia health insurance plan with the Plan ID 89942GA0050031. The plan is called KP GA Signature Silver Virtual Complete 5000.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.12% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.88% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 89942GA0050031 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Georgia | ||||||||||||||||||
| Health Insurance Issuer | Kaiser Foundation Health Plan of Georgia | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 89942GA0050031-03 | ||||||||||||||||||
| Provider Network(s) | ['GAN002'] | ||||||||||||||||||
| 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 - 89942GA0050031-00 Standard On Exchange Plan - 89942GA0050031-01 Open to Indians below 300% FPL - 89942GA0050031-02 Open to Indians above 300% FPL - 89942GA0050031-03 73% AV Silver Plan - 89942GA0050031-04 |
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| Last Plan Update Date | Thu, 24 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of KP GA Signature Silver Virtual Complete 5000 Health Insurance Plan, 89942GA0050031-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $60.00 Copay after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year |
YES | $40.00 Copay after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $60.00 Copay after deductible |
100.00% |
| Dialysis
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Frames from a specified Collection |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Tier 1 generics available @ lower cost share. Tier 2 generics @ cost share shown. Non-preferred generics @ 50% after deductible. Up to a 90 day supply is available through mail order |
YES | $15.00 |
100.00% |
| Habilitation Services
|
YES | $40.00 Copay after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 120.0 Visit(s) per Year |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 30.00% 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 | 30.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $40.00 |
100.00% |
| Non-Preferred Brand Drugs
Up to a 90 day supply is available through mail order |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | $60.00 Copay after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
First 3 visits deductible waived |
YES | $40.00 Copay after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Please refer to Plan Brochure and SBC. |
YES | $40.00 Copay after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Up to a 90 day supply is available through mail order |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
First 3 visits deductible waived |
YES | $40.00 Copay after deductible |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
With limitations |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year 40 visit limit per year for PT and OT combined |
YES | $40.00 Copay after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 40.0 Visit(s) per Year |
YES | $40.00 Copay after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year |
YES | $40.00 |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | $40.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 150.0 Days per Year |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 Copay after deductible |
100.00% |
| Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $40.00 |
100.00% |
| Transplant
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
Non-plan providers are not covered inside the service area. |
YES | $80.00 Copay after deductible |
$80.00 Copay after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Care provided for children from birth through age 5. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 30.00% Coinsurance after deductible |
100.00% |
KP GA Signature Silver Virtual Complete 5000 - AI/LTD Health Insurance Plan Variant 89942GA0050031-03 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 3 |
| 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, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 0.9994 |
| First Tier Utilization | 100% |
| Formulary ID | GAF006 |
| Formulary URL | URL |
| HIOS Product ID | 89942GA005 |
| Import Date | 2023-08-24 11:26:17 |
| 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 | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 70.12% |
| Issuer ID | 89942 |
| Issuer Marketplace Marketing Name | Kaiser Permanente |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | GAN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Urgent and Emergency Care only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Urgent and Emergency Care only |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 89942GA0050031-03 |
| Plan Marketing Name | KP GA Signature Silver Virtual Complete 5000 |
| Plan Type | HMO |
| Plan Variant Marketing Name | KP GA Signature Silver Virtual Complete 5000 - AI/LTD |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,900 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $5,000 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $200 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $3,400 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $10 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | GAS003 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All specialists except Dermatology, Behavioral Health, Optometry, Ophthamology, Obestetrical and Gynecology require a referral. |
| Plan ID | 89942GA0050031 |
| State Code | GA |
| 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 | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $10000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,000 |
| 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 | $17200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8600 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,600 |
| 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 KP GA Signature Silver Virtual Complete 5000 Health Insurance Plan, 89942GA0050031
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about KP GA Signature Silver Virtual Complete 5000, 89942GA0050031 Health Insurance Plan, 89942GA0050031
-
Does KP GA Signature Silver Virtual Complete 5000 Health Insurance Plan, 89942GA0050031 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (89942GA0050031) Health Insurance Plan, Variant (89942GA0050031-03) offer Disease Management Programs?
Does (89942GA0050031) Health Insurance Plan, Variant (89942GA0050031-03) have Out Of Country Coverage?
Does (89942GA0050031) Health Insurance Plan, Variant (89942GA0050031-03) have Out of Service Area Coverage?
Does (89942GA0050031) Health Insurance Plan, Variant (89942GA0050031-03) offer Disease Management Programs?
Does KP GA Signature Silver Virtual Complete 5000 - AI/LTD Health Insurance Plan, Variant (89942GA0050031-03) offer Disease Management Programs for Asthma?
Does KP GA Signature Silver Virtual Complete 5000 - AI/LTD Health Insurance Plan, Variant (89942GA0050031-03) offer Disease Management Programs for Heart disease?
Does KP GA Signature Silver Virtual Complete 5000 - AI/LTD Health Insurance Plan, Variant (89942GA0050031-03) offer Disease Management Programs for Depression?
Does KP GA Signature Silver Virtual Complete 5000 - AI/LTD Health Insurance Plan, Variant (89942GA0050031-03) offer Disease Management Programs for Diabetes?
Does KP GA Signature Silver Virtual Complete 5000 - AI/LTD Health Insurance Plan, Variant (89942GA0050031-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does KP GA Signature Silver Virtual Complete 5000 - AI/LTD Health Insurance Plan, Variant (89942GA0050031-03) offer Disease Management Programs for Low back pain?
Does KP GA Signature Silver Virtual Complete 5000 - AI/LTD Health Insurance Plan, Variant (89942GA0050031-03) 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