University Community Care Plan by Community First - Gold Plan - 63251TX0010001 Health Insurance Plan
Community First Insurance Plans health insurance plan with the Plan ID 63251TX0010001. The plan is called University Community Care Plan by Community First - Gold Plan.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.33% (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 20.67% 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 | 63251TX0010001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | Community First Insurance Plans | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 63251TX0010001-00 | ||||||||||||||||||
| Provider Network(s) | ['TXN001'] | ||||||||||||||||||
| 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 - 63251TX0010001-00 Standard On Exchange Plan - 63251TX0010001-01 |
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| Last Plan Update Date | Wed, 31 Jan 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of University Community Care Plan by Community First - Gold Plan Health Insurance Plan, 63251TX0010001-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $800.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Preauthorization is required when not provided by an Allergist or Immunologist. |
YES | $65.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Cancer Chemotherapy: requires preauthorization for any medication greater than $500 per dose. |
YES | $600.00 |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
YES | $65.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section. Stays longer than the "global stay" requires preauthorization. |
YES | $800.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $0.00 |
100.00% |
| Dialysis
|
YES | $65.00 |
100.00% |
| Durable Medical Equipment
Preauthorization is required. |
YES | $65.00 |
100.00% |
| Emergency Room Services
|
YES | $250.00 |
$250.00 |
| Emergency Transportation/Ambulance
|
YES | $250.00 |
$250.00 |
| Eye Glasses for Children
|
YES | $40.00 |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
|
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 35.0 Visit(s) per Year Preauthorization is required. Habilitative and rehabilitative limits cannot be combined for plans issued or renewed on or after January 1, 2017. Habilitation services includes autism services, and the benchmark plan does not impose age or maximums on autism coverage. |
YES | $125.00 |
100.00% |
| Hearing Aids
Preauthorization is required. To restore or correction of impaired speech or hearing loss. |
YES | $65.00 |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Preauthorization is required. |
YES | $65.00 |
100.00% |
| Hospice Services
Preauthorization may be required. |
YES | $65.00 |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Preauthorization is required for an MRI/MRA if not ordered by a Neurosurgeon or Orthopedic Surgeon. Preauthorization is required for an SPECT/3D imaging/CTA if not ordered by a cardiologist or cardiothoracic surgeon. |
YES | $125.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Preauthorization is required. Any injectable medication, including chemotherapy, greater than $500 per dose. Based on billed charges. NDC, HCPCS and billable units are required on the claim. |
YES | $65.00 |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Preauthorization is required. All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units. |
YES | $800.00 Copay per Stay |
100.00% |
| Inpatient Physician and Surgical Services
Preauthorization is required. |
YES | $0.00 |
100.00% |
| Laboratory Outpatient and Professional Services
Preauthorization is required for all Genetic testing. |
YES | $125.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Preauthorization is required. |
YES | $800.00 Copay per Stay |
100.00% |
| Mental/Behavioral Health Outpatient Services
Preauthorization may be required. |
YES | $40.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $50.00 |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| OTC Card
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $40.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Preauthorization may be required. |
YES | $125.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Preauthorization is required. Limited to combined 35 visits per year, including Chiropractic. |
YES | $125.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Preauthorization may be required. Any procedure that could be deemed as cosmetic requires authorization. |
YES | $600.00 |
100.00% |
| Preferred Brand Drugs
|
YES | $25.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $40.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | $0.00 |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $40.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Preauthorization is required. Medically necessary foot orthotics are not subject to a calendar year maximum. |
YES | $65.00 |
100.00% |
| Radiation
|
YES | $600.00 |
100.00% |
| Reconstructive Surgery
Preauthorization is required. Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. |
YES | $800.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Preauthorization is required. |
YES | $125.00 |
100.00% |
| Rehabilitative Speech Therapy
Preauthorization is required. |
YES | $125.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
|
YES | $40.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 25.0 Visit(s) per Year Preauthorization is required. |
YES | $300.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $65.00 |
100.00% |
| Specialty Drugs
Prior authorization may apply to select specialty medications. |
YES | 30.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
Preauthorization is required. |
YES | $800.00 Copay per Stay |
100.00% |
| Substance Abuse Disorder Outpatient Services
Preauthorization may be required. Certain services require preauthorization. |
YES | $40.00 |
100.00% |
| Transplant
Preauthorization is required. |
YES | $800.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Preauthorization is required. Though state law only mandates coverage for temporomandibular joint (TMJ) disorders for large group plans and HMOs, the benchmark plan covers TMJ. Therefore, it is considered part of the EHB package for Texas. |
YES | $65.00 |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $40.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | $0.00 |
100.00% |
| X-rays and Diagnostic Imaging
Preauthorization is required for Sleep Studies and Video EEG Monitoring. |
YES | $125.00 |
100.00% |
University Community Care Plan by Community First - Gold Plan Health Insurance Plan Variant 63251TX0010001-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7932632320908409 |
| 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 Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | TXF005 |
| Formulary URL | URL |
| HIOS Product ID | 63251TX001 |
| Import Date | 2024-01-31 01:02:00 |
| 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 | 63251 |
| Issuer Marketplace Marketing Name | Community First |
| 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 | TXN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 63251TX0010001-00 |
| Plan Marketing Name | University Community Care Plan by Community First - Gold Plan |
| Plan Type | EPO |
| Plan Variant Marketing Name | University Community Care Plan by Community First - Gold Plan |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,900 |
| 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 | $1,500 |
| 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 | $1,600 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TXS001 |
| Source Name | HIOS |
| Plan ID | 63251TX0010001 |
| 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 |
| 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 | 30.00% |
| 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 | $14500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7250 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,250 |
| 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 University Community Care Plan by Community First - Gold Plan Health Insurance Plan, 63251TX0010001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about University Community Care Plan by Community First - Gold Plan, 63251TX0010001 Health Insurance Plan, 63251TX0010001
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Does University Community Care Plan by Community First - Gold Plan Health Insurance Plan, 63251TX0010001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (63251TX0010001) Health Insurance Plan, Variant (63251TX0010001-00) offer Disease Management Programs?
Does (63251TX0010001) Health Insurance Plan, Variant (63251TX0010001-00) have Out Of Country Coverage?
Does (63251TX0010001) Health Insurance Plan, Variant (63251TX0010001-00) have Out of Service Area Coverage?
Does (63251TX0010001) Health Insurance Plan, Variant (63251TX0010001-00) offer Disease Management Programs?
Does University Community Care Plan by Community First - Gold Plan Health Insurance Plan, Variant (63251TX0010001-00) offer Disease Management Programs for Asthma?
Does University Community Care Plan by Community First - Gold Plan Health Insurance Plan, Variant (63251TX0010001-00) offer Disease Management Programs for Depression?
Does University Community Care Plan by Community First - Gold Plan Health Insurance Plan, Variant (63251TX0010001-00) offer Disease Management Programs for Diabetes?
Does University Community Care Plan by Community First - Gold Plan Health Insurance Plan, Variant (63251TX0010001-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does University Community Care Plan by Community First - Gold Plan Health Insurance Plan, Variant (63251TX0010001-00) offer Disease Management Programs for Pregnancy?
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