SoloCare No Referral HMO Standard Platinum - 83761GA0110047 Health Insurance Plan
Alliant Health Plans health insurance plan with the Plan ID 83761GA0110047. The plan is called SoloCare No Referral HMO Standard Platinum.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 88.10% (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 11.90% 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 | 83761GA0110047 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 83761GA0110047-00 | ||||||||||||||||||
| 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 | Standard Off Exchange Plan - 83761GA0110047-00 Standard On Exchange Plan - 83761GA0110047-01 |
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| 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 Platinum Health Insurance Plan, 83761GA0110047-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 0.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 0.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 0.00% |
100.00% |
| Chiropractic Care
|
NO | ||
| Cosmetic Surgery
|
YES | 0.00% |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | $350.00 |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Procedure(s) per Year |
NO | ||
| Diabetes Education
|
YES | 0.00% |
100.00% |
| Dialysis
|
YES | 0.00% |
100.00% |
| Durable Medical Equipment
|
YES | 0.00% |
100.00% |
| Emergency Room Services
|
YES | $100.00 |
$100.00 |
| Emergency Transportation/Ambulance
|
YES | $100.00 |
$100.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 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% |
100.00% |
| Generic Drugs
Exclusions: Excludes infertility services including medications. |
YES | $5.00 |
$5.00 |
| 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 | $10.00 |
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% |
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% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $100.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Insulin infusion devices. |
YES | 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $350.00 Copay per Stay |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $30.00 |
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 | $350.00 Copay per Stay |
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 | $10.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: Excludes infertility services including medications. |
YES | $50.00 |
$50.00 |
| Nutritional Counseling
Limit: 4.0 Visit(s) per Year |
YES | 0.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $10.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $150.00 |
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 | $10.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $150.00 |
100.00% |
| Preferred Brand Drugs
Exclusions: Excludes infertility services including medications. |
YES | $10.00 |
$10.00 |
| Prenatal and Postnatal Care
|
YES | $10.00 |
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% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $10.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 0.00% |
100.00% |
| Radiation
|
YES | 0.00% |
100.00% |
| Reconstructive Surgery
|
YES | 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year |
YES | $10.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 40.0 Visit(s) per Year |
YES | $10.00 |
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% |
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 | $150.00 Copay per Stay |
100.00% |
| Specialist Visit
|
YES | $20.00 |
100.00% |
| Specialty Drugs
Exclusions: Excludes infertility services including medications. |
YES | $150.00 |
$150.00 |
| Substance Abuse Disorder Inpatient Services
|
YES | $350.00 Copay per Stay |
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 | $10.00 |
100.00% |
| Transplant
Limit: 10000.0 Dollars per Procedure Limited to a combined maximum of $10,000 per covered organ transplant. |
YES | 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 0.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $15.00 |
100.00% |
| Weight Loss Programs
Limit: 4.0 Visit(s) per Year |
YES | 0.00% |
100.00% |
| Well Baby Visits and Care
Care provided for birth through age 5. |
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $30.00 |
100.00% |
SoloCare No Referral HMO Standard Platinum Health Insurance Plan Variant 83761GA0110047-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.881006609521807 |
| 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 Platinum Off Exchange Plan |
| 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 | GAF001 |
| 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 | New |
| 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 | Platinum |
| 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) | 83761GA0110047-00 |
| Plan Marketing Name | SoloCare No Referral HMO Standard Platinum |
| Plan Type | HMO |
| Plan Variant Marketing Name | SoloCare No Referral HMO Standard Platinum |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,000 |
| 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 | $500 |
| 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 | $600 |
| 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 | 83761GA0110047 |
| 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 | 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 | 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 | $6400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $3200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,200 |
| 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 | 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 Platinum Health Insurance Plan, 83761GA0110047
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about SoloCare No Referral HMO Standard Platinum, 83761GA0110047 Health Insurance Plan, 83761GA0110047
-
Does SoloCare No Referral HMO Standard Platinum Health Insurance Plan, 83761GA0110047 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (83761GA0110047) Health Insurance Plan, Variant (83761GA0110047-00) offer Disease Management Programs?
Does (83761GA0110047) Health Insurance Plan, Variant (83761GA0110047-00) have Out Of Country Coverage?
Does (83761GA0110047) Health Insurance Plan, Variant (83761GA0110047-00) have Out of Service Area Coverage?
Does (83761GA0110047) Health Insurance Plan, Variant (83761GA0110047-00) offer Disease Management Programs?
Does SoloCare No Referral HMO Standard Platinum Health Insurance Plan, Variant (83761GA0110047-00) offer Disease Management Programs for Asthma?
Does SoloCare No Referral HMO Standard Platinum Health Insurance Plan, Variant (83761GA0110047-00) offer Disease Management Programs 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