SoloCare No Referral HMO Standard Expanded Bronze - 83761GA0110027 Health Insurance Plan

Alliant Health Plans health insurance plan with the Plan ID 83761GA0110027. The plan is called SoloCare No Referral HMO Standard Expanded Bronze.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 83761GA0110027
Health Insurance Plan Year 2024
State Georgia
Health Insurance Issuer Alliant Health Plans
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 83761GA0110027-02
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).

Providers Georgia All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 83761GA0110027-00

Standard On Exchange Plan - 83761GA0110027-01

Open to Indians below 300% FPL - 83761GA0110027-02

Open to Indians above 300% FPL - 83761GA0110027-03

Last Plan Update Date Wed, 29 Nov 2023 00:00 GMT
Last Import Date Thu, 21 Nov 2024 00:44 GMT

Benefits of SoloCare No Referral HMO Standard Expanded Bronze Health Insurance Plan, 83761GA0110027-02

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

$0.00, 0.00%

100.00%
Acupuncture
NO
Allergy Testing
YES

$0.00, 0.00%

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

$0.00, 0.00%

100.00%
Chiropractic Care
NO
Cosmetic Surgery
YES

$0.00, 0.00%

100.00%
Delivery and All Inpatient Services for Maternity Care
YES

$0.00, 0.00%

100.00%
Dental Check-Up for Children

Limit: 2.0 Procedure(s) per Year

NO
Diabetes Education
YES

$0.00, 0.00%

100.00%
Dialysis
YES

$0.00, 0.00%

100.00%
Durable Medical Equipment
YES

$0.00, 0.00%

100.00%
Emergency Room Services
YES

$0.00, 0.00%

$0.00, 0.00%
Emergency Transportation/Ambulance
YES

$0.00, 0.00%

$0.00, 0.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

$0.00, 0.00%

100.00%
Gender Affirming Care

AHP will cover Gender-Affirming Care that is deemed medically necessary through a review of clinical documentation provided as part of our utilization management processes

YES

$0.00, 0.00%

100.00%
Generic Drugs

Exclusions: Excludes infertility services including medications.

YES

$0.00, 0.00%

$0.00, 0.00%
Habilitation Services

Limit: 40.0 Visit(s) per Year

Exclusions: Hypnotherapy; Excluded forms of therapy include, but are not limited to, vestibular rehabilitation, primal therapy, chelation therapy, rolfing, psychodrama, megavitamin therapy, purging, bioenergetics therapy, cognitive therapy, electromagnetic therapy, vision perception training (orthoptics), salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, actinic changes and/or which are performed as a treatment for acne, services and supplies for smoking cessation programs and treatment of nicotine addiction, and carbon dioxide. Self-Help - Biofeedback, recreational, educational or sleep therapy or other forms of self-care or self-help training and any related diagnostic testing.

Habilitation is classified the same as Rehabilitation under medical/surgical benefits not mental health/substance abuse.

YES

$0.00, 0.00%

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 120.0 Visit(s) per Year

Exclusions: Covered services for Home Health do not include: Food, housing, homemaker services, sitters, home-delivered meals; Home Health Care Services which are not Medically Necessary or of a non-skilled level of care. Services of a person who ordinarily resides in the patient's home or is a member of the family of either the patient or the patient's spouse. Any services for any period during with the Member is not under the continuing care of a PHysician, Convalescent or Custodial Care where the Member has spent a period of time recovery of an illness or surgery and where skilled care is not required or the services being rendered are only for aid in daily living, i.e., for the convenience of the patient. Any services or supplies not specifically listed as Covered Services. Routine care and/or examination of a newborn child. Dietician services. Maintenance therapy. Dialysis treatment. Purchase or rental of dialysis equipment. Private duty nursing care.

Medical treatment provided in the home on a part time or intermittent basis including visits by a licensed health care professional, including a nurse, therpaist, or home health aide; and physical speech, and occupational therapy. When these therapy services are provided as part of home health they are not subject to separate visit limits for therapy services.

YES

$0.00, 0.00%

100.00%
Hospice Services

Exclusions: Hospice care covered expenses do not include: A confinement not required for acute pain control or other treatment for an acute phase of chronic symptom management.

YES

$0.00, 0.00%

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$0.00, 0.00%

100.00%
Infertility Treatment
NO
Infusion Therapy

Insulin infusion devices.

YES

$0.00, 0.00%

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

$0.00, 0.00%

100.00%
Inpatient Physician and Surgical Services
YES

$0.00, 0.00%

100.00%
Laboratory Outpatient and Professional Services
YES

$0.00, 0.00%

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

$0.00, 0.00%

100.00%
Mental/Behavioral Health Outpatient Services

Services are sub-classified as office visit and all other intensive outpatient therapy and partial hospitalization programs are subject to coinsurance.

YES

$0.00, 0.00%

100.00%
Non-Preferred Brand Drugs

Exclusions: Excludes infertility services including medications.

YES

$0.00, 0.00%

$0.00, 0.00%
Nutritional Counseling

Limit: 4.0 Visit(s) per Year

YES

$0.00, 0.00%

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$0.00, 0.00%

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

$0.00, 0.00%

100.00%
Outpatient Rehabilitation Services

Limit: 40.0 Visit(s) per Year

Exclusions: Hypnotherapy; Excluded forms of therapy include, but are not limited to, vestibular rehabilitation, primal therapy, chelation therapy, rolfing, psychodrama, megavitamin therapy, purging, bioenergetics therapy, cognitive therapy, electromagnetic therapy, vision perception training (orthoptics), salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, actinic changes and/or which are performed as a treatment for acne, services and supplies for smoking cessation programs and treatment of nicotine addiction, and carbon dioxide. Self-Help - Biofeedback, recreational, educational or sleep therapy or other forms of self-care or self-help training and any related diagnostic testing.

YES

$0.00, 0.00%

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$0.00, 0.00%

100.00%
Preferred Brand Drugs

Exclusions: Excludes infertility services including medications.

YES

$0.00, 0.00%

$0.00, 0.00%
Prenatal and Postnatal Care
YES

$0.00, 0.00%

100.00%
Preventive Care/Screening/Immunization

The recommendations by the USPSTF for breast cancer screenings, mammography and preventions issued prior to November 2009 will be considered current. Immunizations covered are those recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC).

YES

$0.00, 0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$0.00, 0.00%

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

$0.00, 0.00%

100.00%
Radiation
YES

$0.00, 0.00%

100.00%
Reconstructive Surgery
YES

$0.00, 0.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Year

YES

$0.00, 0.00%

100.00%
Rehabilitative Speech Therapy

Limit: 40.0 Visit(s) per Year

YES

$0.00, 0.00%

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

$0.00, 0.00%

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Year

Beneifts will not be provided when: A Member reaches the maximum level of recovery possible and no longer requires other than routine care; Care is primarily Custodial Care, not requiring definitive medical or 24-hour-a-day nursing service; Care is for chronic brain syndromes for which no specific medical conditions exist that require care in a Skilled Nursing Faciliy; A Member is undergoing senile deterioration, mental deficiency or retardation, and has no medical condition requiring care; The care rendered is for other than Skilled Convalescent Care.

YES

$0.00, 0.00%

100.00%
Specialist Visit
YES

$0.00, 0.00%

100.00%
Specialty Drugs

Exclusions: Excludes infertility services including medications.

YES

$0.00, 0.00%

$0.00, 0.00%
Substance Abuse Disorder Inpatient Services
YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Outpatient Services

Services are sub-classified as office visit and all other intensive outpatient therapy and partial hospitalization programs are subject to coinsurance.

YES

$0.00, 0.00%

100.00%
Transplant

Limit: 10000.0 Dollars per Procedure

Limited to a combined maximum of $10,000 per covered organ transplant.

YES

$0.00, 0.00%

100.00%
Treatment for Temporomandibular Joint Disorders
YES

$0.00, 0.00%

100.00%
Urgent Care Centers or Facilities
YES

$0.00, 0.00%

100.00%
Weight Loss Programs

Limit: 4.0 Visit(s) per Year

YES

$0.00, 0.00%

100.00%
Well Baby Visits and Care

Care provided for birth through age 5.

YES

$0.00, 0.00%

100.00%
X-rays and Diagnostic Imaging
YES

$0.00, 0.00%

100.00%

SoloCare No Referral HMO Standard Expanded Bronze (AI/AN Zero Cost Share) Health Insurance Plan Variant 83761GA0110027-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1.0
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 Zero Cost Sharing Plan Variation
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Diabetes
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID GAF006
Formulary URL URL
HIOS Product ID 83761GA011
Import Date 2023-11-29 20:03:17
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? No
Issuer ID 83761
Issuer Marketplace Marketing Name Alliant Health Plans
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID GAN001
Out of Country Coverage No
Out of Country Coverage Description Coverage is available for emergency situations
Out of Service Area Coverage No
Out of Service Area Coverage Description In-Network providers available in certain Tennessee counties that border Georgia. Verify participating providers at AlliantPlans.com
Plan Brochure URL
Plan Effective Date 2024-01-01
Plan Expiration Date 2024-12-31
Plan ID (Standard Component ID with Variant) 83761GA0110027-02
Plan Marketing Name SoloCare No Referral HMO Standard Expanded Bronze
Plan Type HMO
Plan Variant Marketing Name SoloCare No Referral HMO Standard Expanded Bronze (AI/AN Zero Cost Share)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
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 $0
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 $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID GAS001
Source Name SERFF
Plan ID 83761GA0110027
State Code GA
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $0
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $0
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $0
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $0
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of SoloCare No Referral HMO Standard Expanded Bronze Health Insurance Plan, 83761GA0110027

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about SoloCare No Referral HMO Standard Expanded Bronze, 83761GA0110027 Health Insurance Plan, 83761GA0110027

  • Does SoloCare No Referral HMO Standard Expanded Bronze Health Insurance Plan, 83761GA0110027 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (83761GA0110027) Health Insurance Plan, Variant (83761GA0110027-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Diabetes

    Does (83761GA0110027) Health Insurance Plan, Variant (83761GA0110027-02) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan). Details: Coverage is available for emergency situations

    Does (83761GA0110027) Health Insurance Plan, Variant (83761GA0110027-02) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: In-Network providers available in certain Tennessee counties that border Georgia. Verify participating providers at AlliantPlans.com

    Does (83761GA0110027) Health Insurance Plan, Variant (83761GA0110027-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Diabetes

    Does SoloCare No Referral HMO Standard Expanded Bronze (AI/AN Zero Cost Share) Health Insurance Plan, Variant (83761GA0110027-02) offer Disease Management Programs for Asthma?

    Yes, the SoloCare No Referral HMO Standard Expanded Bronze (AI/AN Zero Cost Share) Health Insurance Plan Variant 83761GA0110027-02 offers Disease Management Program for Asthma.

    Does SoloCare No Referral HMO Standard Expanded Bronze (AI/AN Zero Cost Share) Health Insurance Plan, Variant (83761GA0110027-02) offer Disease Management Programs for Diabetes?

    Yes, the SoloCare No Referral HMO Standard Expanded Bronze (AI/AN Zero Cost Share) Health Insurance Plan Variant 83761GA0110027-02 offers Disease Management Program for Diabetes.

 

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