KP Gold 4500/0%/$30/S11 - 89942GA0060028 Health Insurance Plan
Kaiser Foundation Health Plan of Georgia health insurance plan with the Plan ID 89942GA0060028. The plan is called KP Gold 4500/0%/$30/S11.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.44% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.56% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 89942GA0060028 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 89942GA0060028-01 | ||||||||||||||||||
| Provider Network(s) | ['GAN001'] | ||||||||||||||||||
| 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 | |||||||||||||||||||
| Last Plan Update Date | Thu, 24 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of KP Gold 4500/0%/$30/S11 Health Insurance Plan, 89942GA0060028-01
| 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
Exclusions: 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% |
KP Gold 4500/0%/$30/S11 Health Insurance Plan Variant 89942GA0060028-01 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 On 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 | 78.44% |
| 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 | $9000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $4500 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $4,500 |
| 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) | 89942GA0060028-01 |
| Plan Marketing Name | KP Gold 4500/0%/$30/S11 |
| Plan Type | HMO |
| Plan Variant Marketing Name | KP Gold 4500/0%/$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 | $4,500 |
| 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 | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,600 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $100 |
| 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 | 89942GA0060028 |
| 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 |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of KP Gold 4500/0%/$30/S11 Health Insurance Plan, 89942GA0060028
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about KP Gold 4500/0%/$30/S11, 89942GA0060028 Health Insurance Plan, 89942GA0060028
-
Does KP Gold 4500/0%/$30/S11 Health Insurance Plan, 89942GA0060028 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (89942GA0060028) Health Insurance Plan, Variant (89942GA0060028-01) offer Disease Management Programs?
Does (89942GA0060028) Health Insurance Plan, Variant (89942GA0060028-01) have Out Of Country Coverage?
Does (89942GA0060028) Health Insurance Plan, Variant (89942GA0060028-01) have Out of Service Area Coverage?
Does (89942GA0060028) Health Insurance Plan, Variant (89942GA0060028-01) offer Disease Management Programs?
Does KP Gold 4500/0%/$30/S11 Health Insurance Plan, Variant (89942GA0060028-01) offer Disease Management Programs for Asthma?
Does KP Gold 4500/0%/$30/S11 Health Insurance Plan, Variant (89942GA0060028-01) offer Disease Management Programs for Heart disease?
Does KP Gold 4500/0%/$30/S11 Health Insurance Plan, Variant (89942GA0060028-01) offer Disease Management Programs for Depression?
Does KP Gold 4500/0%/$30/S11 Health Insurance Plan, Variant (89942GA0060028-01) offer Disease Management Programs for Diabetes?
Does KP Gold 4500/0%/$30/S11 Health Insurance Plan, Variant (89942GA0060028-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does KP Gold 4500/0%/$30/S11 Health Insurance Plan, Variant (89942GA0060028-01) offer Disease Management Programs for Low back pain?
Does KP Gold 4500/0%/$30/S11 Health Insurance Plan, Variant (89942GA0060028-01) 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