Vantage Health Plan, Inc. health insurance plan with the Plan ID 67243LA0090045. The plan is called Standard Gold 2000.
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 | 67243LA0090045 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Louisiana | ||||||||||||||||||
Health Insurance Issuer | Vantage Health Plan, Inc. | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 67243LA0090045-02 | ||||||||||||||||||
Provider Network(s) | ['LAN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 67243LA0090045-00 Standard On Exchange Plan - 67243LA0090045-01 |
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Last Plan Update Date | Thu, 18 Aug 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Basic Dental Care - Child
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Chemotherapy
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Chiropractic Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
Minimum stay of 48 hours |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Diabetes Education
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Dialysis
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Durable Medical Equipment
Various limitations apply as stated in the Benchmark plan. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Emergency Room Services
The ER Copay is waived if the visit results in an inpatient admission. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Emergency Transportation/Ambulance
Air ambulance services are covered in only specified situations. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Eye Glasses for Children
Limit: 1.0 Visit(s) per Year |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
Quantity limits, authorizations and step therapy limits may apply. |
YES | $0.00, 0.00% |
100.00% |
Habilitation Services
Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Hearing Aids
Limit: 1.0 Item(s) per 3 Years |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Home Health Care Services
Home Health Care services provided to a Member in lieu of an Inpatient Hospital Admission are covered; must obtain authorization. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Hospice Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
Copays, if applicable, are per day for first three days only. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Inpatient Physician and Surgical Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Laboratory Outpatient and Professional Services
Lab services in the Emergency Room are subject to the deductible, if applicable. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Major Dental Care - Child
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Mental/Behavioral Health Inpatient Services
Inpatient treatment for mental/behavioral health disorders must be Authorized as provided in the Care Management Article of this Benefit Plan. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Mental/Behavioral Health Outpatient Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Non-Preferred Brand Drugs
Quantity limits, authorizations and step therapy limits may apply. |
YES | $0.00 |
100.00% |
Nutritional Counseling
Limit: 4.0 Visit(s) per Benefit Period Coverage only for diabetes education. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Medically Necessary orthodontia only. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Other Practitioner Office Visit (Nurse, Physician Assistant)
Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Outpatient Rehabilitation Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Preferred Brand Drugs
Quantity limits, authorizations and step therapy limits may apply. |
YES | $0.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Preventive Care/Screening/Immunization
Quantitative limit units apply, see Benchmark plan. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Primary Care Visit to Treat an Injury or Illness
Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Private-Duty Nursing
Limit: 150.0 Hours per Benefit Period Inpatient private-duty nursing services are not covered. |
YES | $0.00, 0.00% |
100.00% |
Prosthetic Devices
Various limitations apply as stated in the Benchmark plan. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Radiation
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Reconstructive Surgery
Plan only outlines benefits for breast reconstruction. Must be medically necessary and related to mastectomy. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Occupational and Physical Therapies are included in the Outpatient Rehabilitation Services benefit listed in Line 91 above. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Rehabilitative Speech Therapy
Rehabilitative Speech Therapy is included in the Outpatient Rehabilitation Services benefit listed in Line 91 above. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year Covers exam and cleaning |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Year An added benefit |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Routine Foot Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Skilled Nursing Facility
Three-day prior inpatient stay |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Specialist Visit
Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Specialty Drugs
Specialty drugs may be limited to a thirty (30) day supply. Quantity limits, authorizations and step therapy limits may apply. |
YES | $0.00 |
100.00% |
Substance Abuse Disorder Inpatient Services
Inpatient treatment for substance abuse must be Authorized as provided in the Care Management Article of this Benefit Plan, when coverage for alcohol and/or drug abuse is provided. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Substance Abuse Disorder Outpatient Services
Covered Services will be only those, which are for treatment for abuse of alcohol, drugs or other chemicals, and the resultant physiological and/or psychological dependency, which develops with continued use. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Transplant
Exclusions: Non-EHB and out-of-network transplant services |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Treatment for Temporomandibular Joint Disorders
|
NO | ||
Urgent Care Centers or Facilities
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Weight Loss Programs
Exclusions: Non-Vantage Weight Loss programs are excluded. Vantage Weight Loss programs are covered as part of the Vantage Wellness Program. |
YES | $0.00, 0.00% |
100.00% |
Well Baby Visits and Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
X-rays and Diagnostic Imaging
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 1 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
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 2 |
Disease Management Programs Offered | Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Weight Loss Programs |
EHB Percent of Total Premium | 0.976658 |
First Tier Utilization | 100% |
Formulary ID | LAF001 |
Formulary URL | URL |
HIOS Product ID | 67243LA009 |
Import Date | 8/18/2022 1:00 |
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 | 67243 |
Issuer Marketplace Marketing Name | Vantage Health Plan |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Gold |
Multiple In Network Tiers | No |
National Network | No |
Network ID | LAN001 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Limited to Emergency Services only. Covered as in-network. |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Out-of-Network Deductible and Co-insurance |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan ID (Standard Component ID with Variant) | 67243LA0090045-02 |
Plan Marketing Name | Standard Gold 2000 |
Plan Type | POS |
Plan Variant Marketing Name | Standard Gold 2000 Zero |
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 | $0 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $0 |
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 | $0 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | LAS001 |
Source Name | HIOS |
Plan ID | 67243LA0090045 |
State Code | LA |
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 | Yes |
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, 20 Aug 2024 06:14 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