Platinum 90 HMO - 20523CA0110025 Health Insurance Plan
Aetna Health of California, Inc. health insurance plan with the Plan ID 20523CA0110025. The plan is called Platinum 90 HMO.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 90.74% (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 9.26% 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 | 20523CA0110025 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | California | ||||||||||||||||||
| Health Insurance Issuer | Aetna Health of California, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 20523CA0110025-03 | ||||||||||||||||||
| Provider Network(s) | PREFERRED NON-PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 20523CA0110025-01 |
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| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Platinum 90 HMO AI-AN Health Insurance Plan Variant 20523CA0110025-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.9074 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 10.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 99% |
| First Tier Utilization | 100% |
| Formulary ID | CAF004 |
| HIOS Product ID | 20523CA011 |
| Import Date | 2/12/2024 |
| Inpatient Copayment Maximum Days | 5 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer ID | 20523 |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 10.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Platinum |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | CAN004 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Except for Emergencies |
| Plan Effective Date | 1/1/2024 |
| Plan ID (Standard Component ID with Variant) | 20523CA0110025-03 |
| Plan Marketing Name | Platinum 90 HMO |
| Plan Type | HMO |
| Plan Variant Marketing Name | Platinum 90 HMO AI-AN |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $600 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | CAS004 |
| Source Name | SERFF |
| Specialist Requiring a Referral | Referral required for all physicians EXCEPT OB/GYN, ER, Internal Medicine, Family Practice, General Medicine and Pediatrician. |
| Specialty Drug Maximum Coinsurance | $250 |
| Plan ID | 20523CA0110025 |
| State Code | CA |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family | per person not applicable | per group 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 | $4500 per person | $9000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $4,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Platinum 90 HMO Health Insurance Plan, 20523CA0110025
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Platinum 90 HMO, 20523CA0110025 Health Insurance Plan, 20523CA0110025
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Does Platinum 90 HMO Health Insurance Plan, 20523CA0110025 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (20523CA0110025) Health Insurance Plan, Variant (20523CA0110025-03) offer Disease Management Programs?
Does (20523CA0110025) Health Insurance Plan, Variant (20523CA0110025-03) have Out Of Country Coverage?
Does (20523CA0110025) Health Insurance Plan, Variant (20523CA0110025-03) have Out of Service Area Coverage?
Does (20523CA0110025) Health Insurance Plan, Variant (20523CA0110025-03) offer Disease Management Programs?
Does Platinum 90 HMO AI-AN Health Insurance Plan, Variant (20523CA0110025-03) offer Disease Management Programs for Asthma?
Does Platinum 90 HMO AI-AN Health Insurance Plan, Variant (20523CA0110025-03) offer Disease Management Programs for Heart disease?
Does Platinum 90 HMO AI-AN Health Insurance Plan, Variant (20523CA0110025-03) offer Disease Management Programs for Depression?
Does Platinum 90 HMO AI-AN Health Insurance Plan, Variant (20523CA0110025-03) offer Disease Management Programs for Diabetes?
Does Platinum 90 HMO AI-AN Health Insurance Plan, Variant (20523CA0110025-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Platinum 90 HMO AI-AN Health Insurance Plan, Variant (20523CA0110025-03) offer Disease Management Programs for Low back pain?
Does Platinum 90 HMO AI-AN Health Insurance Plan, Variant (20523CA0110025-03) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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