UHC Kelsey-Seybold Gold Copay Focus ($0 PCP Visits, $0 Insulin) - 40220TX0080034 Health Insurance Plan
UnitedHealthcare of Texas, Inc. health insurance plan with the Plan ID 40220TX0080034. The plan is called UHC Kelsey-Seybold Gold Copay Focus ($0 PCP Visits, $0 Insulin).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.77% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.23% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 40220TX0080034 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | UnitedHealthcare of Texas, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 40220TX0080034-01 | ||||||||||||||||||
| Provider Network(s) | NETWORK NON-PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 26 Nov 2024 06:27 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 40220TX0080034-00 Standard On Exchange Plan - 40220TX0080034-01 |
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| Last Plan Update Date | Sat, 16 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 26 Nov 2024 06:27 GMT |
Benefits of UHC Kelsey-Seybold Gold Copay Focus ($0 PCP Visits, $0 Insulin) Health Insurance Plan, 40220TX0080034-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 45.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $40.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 45.00% |
100.00% |
| Chemotherapy
|
YES | 45.00% |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year 35 visits per year for any combination of physical therapy, occupational therapy, speech therapy, and manipulative treatment. |
YES | 45.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services follow inpatient physician/surgeon fees. |
YES | $2,000.00 |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | No Charge |
100.00% |
| Diabetes Education
|
YES | 45.00% |
100.00% |
| Dialysis
|
YES | 45.00% |
100.00% |
| Durable Medical Equipment
|
YES | 45.00% |
100.00% |
| Emergency Room Services
|
YES | $500.00 |
$500.00 |
| Emergency Transportation/Ambulance
|
YES | 45.00% |
45.00% |
| Eye Glasses - Adult
|
NO | ||
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 45.00% |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Limit: 30.0 Days per Month 90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | $5.00 |
100.00% |
| Habilitation Services
Limit: 35.0 Visit(s) per Year 35 visits per year for any combination of physical therapy, occupational therapy, speech therapy, and manipulative treatment. Visit limits do not apply if the primary diagnosis code for the outpatient habilitative services being provided is a covered mental health or substance use disorder. |
YES | $40.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Benefits are limited to a single purchase per hearing impaired ear every 36 months. |
YES | 45.00% |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | 45.00% |
100.00% |
| Hospice Services
|
YES | 45.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $300.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 45.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $2000 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 45.00% |
100.00% |
| Laboratory Outpatient and Professional Services
Limit: 18.0 Visit(s) per Year Limited to 18 Presumptive Drug Tests per year. Limited to 18 Definitive Drug Tests per year. |
YES | No Charge |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 45.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | $2000 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $40.00 |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Days per Month 90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | 45% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Coverage is for medically necessary orthodontia only. |
YES | 50.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 45.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $300.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year 35 visits per year for any combination of physical therapy, occupational therapy, speech therapy, and manipulative treatment. |
YES | $40.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $300.00 |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Days per Month 90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | $50.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Cost sharing for Virtual Primary Care matches in-person office visit. See SBC for additional cost share details. |
YES | No Charge |
100.00% |
| Private-Duty Nursing
Covered inpatient only when medically necessary. |
YES | 45.00% |
100.00% |
| Prosthetic Devices
|
YES | 45.00% |
100.00% |
| Radiation
|
YES | 45.00% |
100.00% |
| Reconstructive Surgery
|
YES | $300.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Year 35 visits for any combination of physical therapy, occupational therapy, speech therapy and manipulative treatments. |
YES | $40.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Year 35 visits for any combination of physical therapy, occupational therapy, speech therapy and manipulative treatments. |
YES | $40.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 25.0 Days per Year Limit will be any combination of Skilled Nursing or Inpatient Rehabilitation Services. Visit limits do not apply to ABI services. |
YES | $2000 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $40.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Days per Month Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply. |
YES | 50% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $2000 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $40.00 |
100.00% |
| Transplant
|
YES | $2,000.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 45.00% |
100.00% |
| Urgent Care Centers or Facilities
$0 Virtual Urgent Care visits. See SBC for additional cost share details. |
YES | $50.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $65.00 |
100.00% |
UHC Kelsey-Seybold Gold Copay Focus ($0 PCP Visits, $0 Insulin) Health Insurance Plan Variant 40220TX0080034-01 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 | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $500 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $500 |
| 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 |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | TXF018 |
| Formulary URL | URL |
| HIOS Product ID | 40220TX008 |
| Import Date | 2023-12-16 01:02:09 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 3 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 81.77% |
| Issuer ID | 40220 |
| Issuer Marketplace Marketing Name | UnitedHealthcare |
| 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 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 | 45.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | TXN003 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area. |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 40220TX0080034-01 |
| Plan Level Exclusions | 0 |
| Plan Marketing Name | UHC Kelsey-Seybold Gold Copay Focus ($0 PCP Visits, $0 Insulin) |
| Plan Type | HMO |
| Plan Variant Marketing Name | UHC Kelsey-Seybold Gold Copay Focus ($0 PCP Visits, $0 Insulin) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $600 |
| SBC Scenario, Having a Baby, Copayment | $4,100 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $70 |
| SBC Scenario, Having Diabetes, Copayment | $1,000 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $800 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TXS002 |
| Source Name | HIOS |
| Specialist Requiring a Referral | All, except OBGYN and as state mandated |
| Plan ID | 40220TX0080034 |
| State Code | TX |
| 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 | $14000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,000 |
| 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 UHC Kelsey-Seybold Gold Copay Focus ($0 PCP Visits, $0 Insulin) Health Insurance Plan, 40220TX0080034
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about UHC Kelsey-Seybold Gold Copay Focus ($0 PCP Visits, $0 Insulin), 40220TX0080034 Health Insurance Plan, 40220TX0080034
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Does UHC Kelsey-Seybold Gold Copay Focus ($0 PCP Visits, $0 Insulin) Health Insurance Plan, 40220TX0080034 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (40220TX0080034) Health Insurance Plan, Variant (40220TX0080034-01) have Out Of Country Coverage?
Does (40220TX0080034) Health Insurance Plan, Variant (40220TX0080034-01) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 26 Nov 2024 06:27 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