Kaiser Foundation Health Plan of Georgia health insurance plan with the Plan ID 89942GA0060012. The plan is called KP Gold 2500/0%/$30/S11.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 80.66% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.34% of the costs of all covered benefits (according to the Issuer).
Health Insurance Plan ID | 89942GA0060012 | ||||||||||||||||||
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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 | 89942GA0060012-00 | ||||||||||||||||||
Provider Network(s) | ['GAN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 27 Aug 2024 05:58 GMT). |
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Available Variants of the Health Plan | |||||||||||||||||||
Last Plan Update Date | Thu, 24 Aug 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 27 Aug 2024 05:58 GMT |
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 |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Chemotherapy
|
YES | $60.00 |
100.00% |
Chiropractic Care
Limit: 20.0 Visit(s) per Year Coverage limited to Spinal Manipulation. |
YES | $60.00 |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Education
|
YES | $60.00 |
100.00% |
Dialysis
|
YES | $60.00 |
100.00% |
Durable Medical Equipment
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | $650.00 |
$650.00 |
Emergency Transportation/Ambulance
|
YES | $650.00 |
$650.00 |
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 at lower cost share. Tier 2 generics at cost share shown. Non-preferred generics see non-preferred brand cost share. Greater member cost share at network pharmacies. Network pharmacies can only be used for initial prescription fills. |
YES | $20.00 |
100.00% |
Habilitation Services
Visit limits may apply. Please refer to Plan Brochure and SBC. |
YES | $60.00 |
100.00% |
Hearing Aids
|
NO | ||
Home Health Care Services
Limit: 120.0 Visit(s) per Year |
YES | No Charge |
100.00% |
Hospice Services
|
YES | No Charge |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | $600.00 |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | $60.00 |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 0.00% 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 | 0.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
|
YES | $30.00 |
100.00% |
Non-Preferred Brand Drugs
Greater member cost share at network pharmacies. Network pharmacies can only be used for initial prescription fills. |
YES | $80.00 |
100.00% |
Nutritional Counseling
|
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 | 0.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Visit limits may apply. Please refer to Plan Brochure and SBC. |
YES | $60.00 |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
Greater member cost share at network pharmacies. Network pharmacies can only be used for initial prescription fills. |
YES | $50.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | $60.00 |
100.00% |
Reconstructive Surgery
with limitations |
YES | 0.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year |
YES | $60.00 |
100.00% |
Rehabilitative Speech Therapy
Limit: 40.0 Visit(s) per Year |
YES | $60.00 |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year |
YES | $30.00 |
100.00% |
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | $30.00 |
100.00% |
Routine Foot Care
|
NO | ||
Skilled Nursing Facility
Limit: 150.0 Days per Year |
YES | 0.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | $60.00 |
100.00% |
Specialty Drugs
Network pharmacies can only be used for initial prescription fills. |
YES | 25.00% |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
100.00% |
Transplant
|
YES | 0.00% 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 | $60.00 |
$60.00 |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
Care provided for birth through age 5. |
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
|
YES | 0.00% Coinsurance after deductible |
100.00% |
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 |
Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 25.00% |
Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
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 |
Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
First Tier Utilization | 100% |
Formulary ID | GAF016 |
Formulary URL | URL |
HIOS Product ID | 89942GA006 |
HSA/HRA Employer Contribution | No |
Import Date | 2023-08-24 11:26:17 |
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 | 80.66% |
Issuer ID | 89942 |
Issuer Marketplace Marketing Name | Kaiser Permanente |
Market Coverage | SHOP (Small Group) |
Medical Drug Deductibles Integrated | No |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
Medical EHB Deductible, In Network (Tier 1), Family Per Group | $5000 per group |
Medical EHB Deductible, In Network (Tier 1), Family Per Person | $2500 per person |
Medical EHB Deductible, In Network (Tier 1), Individual | $2,500 |
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 | GAN001 |
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) | 89942GA0060012-00 |
Plan Marketing Name | KP Gold 2500/0%/$30/S11 |
Plan Type | HMO |
Plan Variant Marketing Name | KP Gold 2500/0%/$30/S11 |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $10 |
SBC Scenario, Having a Baby, Deductible | $2,500 |
SBC Scenario, Having a Baby, Limit | $50 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $1,600 |
SBC Scenario, Having Diabetes, Deductible | $0 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,600 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $500 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | GAS001 |
Source Name | SERFF |
Specialist Requiring a Referral | All specialists except Dermatology, Behavioral Health, Optometry, Ophthamology, Obestetrical and Gynecology require a referral. |
Plan ID | 89942GA0060012 |
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 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17800 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8900 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,900 |
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 |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 27 Aug 2024 05:58 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