AmeriHealth Caritas North Carolina, Inc. health insurance plan with the Plan ID 17414NC0010014. The plan is called AmeriHealth Caritas Next Gold Deluxe + No Referrals.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.61% (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 18.39% 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 | 17414NC0010014 | ||||||||||||||||||
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Health Insurance Plan Year | 2025 | ||||||||||||||||||
State | North Carolina | ||||||||||||||||||
Health Insurance Issuer | AmeriHealth Caritas North Carolina, Inc. | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 17414NC0010014-00 | ||||||||||||||||||
Provider Network(s) | PREFERRED | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 17414NC0010014-00 Standard On Exchange Plan - 17414NC0010014-01 |
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Last Plan Update Date | Fri, 11 Oct 2024 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
Exclusions: Excludes injury related to chewing or biting. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | $30.00 |
100.00% |
Anesthetics
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Bariatric Surgery
For surgical treatment of morbid obesity. Before pursuing bariatric surgery, a complete nutritional, behavioral, and medical evaluation must be completed, and requirements must be met. Bariatric surgery must be medically necessary to be eligible for coverage. Limited to one procedure per lifetime. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Blood and Blood Services
We will cover the cost of the collection or obtainment of blood or blood products from a blood donor, including the Member in the case of autologous blood donation. We will cover the cost of transfusions of blood, plasma, blood plasma expanders and other fluids injected into the bloodstream. Benefits are provided for the cost of storing a Member?s own blood only when it is stored and used for a previously scheduled procedure. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Cardiac Rehabilitation
Limit: 30.0 Visit(s) per Benefit Period Limited to 30 visits per benefit period. More available beyond the initial allotment if deemed medically necessary. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Chemotherapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
Limit: 30.0 Visit(s) per Benefit Period 30 visit limits for PT and OT combined (including chiropractic). |
YES | 20.00% Coinsurance after deductible |
100.00% |
Clinical Trials
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Congenital Anomaly, including Cleft Lip/Palate
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
Exclusions: Dependent children not covered for abortion. Abortion services available for first 16 weeks of pregnancy. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Dental Anesthesia
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Care Management
Includes routine foot care. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Diabetes Education
|
YES | No Charge |
100.00% |
Diagnosis and Treatment of Lymphedema
Exclusions: Over-the-counter compression or elastic knee-high or other stocking products. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Dialysis
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
Exclusions: Appliances and accessories that serve no medical purpose or that are primarily for comfort or convenience; repair or replacement of equipment due to abuse or desire for new equipment. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
Exclusions: Excludes services provided primarily for the convenience of travel, transportation to or from a doctor's office or dialysis center, transportation for the purpose of receiving services that are not considered covered services. |
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | 20.00% Coinsurance after deductible |
100.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document. Certain off-label uses of cancer drugs will be covered in accordance with state law. |
YES | $15.00 |
100.00% |
Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: Cognitive Therapy. Group classes for pulmonary rehabilitation. Combined 30 visit limit for occupational and physical therapies and chiropractic services. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Hearing Aids
Limit: 1.0 Item(s) per 3 Years One hearing aid per hearing impaired ear, and replacement hearing aids, once every 36 months. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Home Health Care Services
Exclusions: Excludes homemaker services, such as cooking and housekeeping; Dietitian services or meals; Services that are provided by a close relative or a member of the household. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Hospice Services
Exclusions: Excludes homemaker services, such as cooking, housekeeping, and food or meal preparation. Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less. |
YES | No Charge after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
Exclusions: Lab tests that are not ordered by Doctor or Other Provider |
YES | 20.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
Limit: 3.0 Treatment(s) per Lifetime Exclusions: Artificial insemination, in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and services for procurement and storage of donor semen/eggs are not covered Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member. The lifetime maximums are described in medical policies, which are guides considered when making coverage determinations. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Infusion Therapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: Admissions primarily for the purpose of receiving diagnostic services or a physical examination; admissions primarily for the purpose of receiving therapy services, except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therapy. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
Exclusions: Lab tests that are not ordered by a Doctor or Other Provider. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
NO | ||
Mental/Behavioral Health Inpatient Services
Exclusions: Excludes, Inpatient confinements that are primarily intended as a change of environment; Counseling with relatives of a patient. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
Exclusions: Excludes counseling with relatives about a patient. Includes biofeedback. Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits. |
YES | $15.00 |
100.00% |
Non-Preferred Brand Drugs
Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document. Certain off-label uses of cancer drugs will be covered in accordance with state law. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Nutritional Counseling
Nutritional counseling visits are separate from the obesity-related office visits. |
YES | No Charge |
100.00% |
Organ Donor Search
If a transplant is provided from a living donor to the recipient MEMBER who will receive the transplant: Benefits are provided for reasonable and necessary services related to the search for a donor. Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient's coverage. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Orthotic Devices for Positional Plagiocephaly
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Other Practitioner Office Visit (Nurse, Physician Assistant)
Additional information can be found on the member's schedule of benefits |
YES | $15.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: Applied Behavior Analysis (ABA) therapy; Cognitive therapy; Speech therapy for stammering or stuttering; Group classes for pulmonary rehabilitation; music therapy, remedial reading, recreational or activity therapy, all forms or special education and supplies or equipment used similarly; maintenance therapy; massage therapy. Combined 30 visit limit for occupational and physical therapies and chiropractic services. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document. Certain off-label uses of cancer drugs will be covered in accordance with state law. |
YES | $100.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
Preventive Care/Screening/Immunization
AHC covers any preventive services required by federal and state laws or regulations at no charge to the member. |
YES | No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits. |
YES | $15.00 |
100.00% |
Private-Duty Nursing
Exclusions: Excludes services provided by a close relative or a member of the household. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Prosthetic Devices
Exclusions: Dental appliances except when medically necessary for the treatment of temporomandibular joint disease or obstructive sleep apnea; cosmetic improvements, such as implants of hair follicles and skin tone enhancements; lenses for keratoconus or any other eye procedure except as specifically covered under the health plan. Prosthetic appliance must replace all or part of a body part or its function. Therapeutic contact lenses may be covered when used as a corneal bandage for a medical condition; benefits include a one-time replacement of eyeglass or contact lenses due to a prescription change following cataract surgery. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Pulmonary Rehabilitation
Limit: 36.0 Treatment(s) per Benefit Period Limited to 2 - 1 hour treatments per day, up to 36 treatments within a benefit period. More available beyond the initial allotment if deemed medically necessary. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period Exclusions: Charges for care not provided in an office setting. Infusion therapy or chelation therapy. Services of a chiropractor or osteopath that are not within their scope of practice, as defined by state law. Combined 30 visit limit for occupational and physical therapies and chiropractic services. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period |
YES | 20.00% Coinsurance after deductible |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period |
YES | 20.00% Coinsurance after deductible |
100.00% |
Routine Foot Care
|
YES | $30.00 |
100.00% |
Sexual Dysfunction
Sexual Dysfunction For Treatment of Organic Disease |
YES | 20.00% Coinsurance after deductible |
100.00% |
Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period Exclusions: Covered health services do not include custodial, domiciliary care, or long-term care admissions. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Specialist Visit
Dermatology virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits. |
YES | $30.00 |
100.00% |
Specialty Drugs
Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document. Certain off-label uses of cancer drugs will be covered in accordance with state law. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Sterilization
Tubal Ligation is covered in full under Preventive Care. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
Exclusions: Excludes, Inpatient confinements that are primarily intended as a change of environment; Counseling with relatives of a patient. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
Exclusions: Excludes counseling with relatives about a patient. Includes biofeedback. Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits. |
YES | $15.00 |
100.00% |
Transplant
Exclusions: The purchase price of organs or tissue if any organ or tissue is sold rather than donated to the recipient member; the procurement of organs, tissue, bone marrow, or peripheral blood stem cells or any other donor services if a recipient is not a member; transplants, including high dose chemotherapy, considered experimental or investigational; services for or related to the transplantation of animal or artificial organs or tissues. Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient's coverage. Reasonable costs for travel and lodging are covered and will be reimbursed for a covered transplant based on AmeriHealth guidelines available from our transplant coordinator. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
Exclusions: Coverage is not provided for orthodontic braces, crowns, bridges, dentures, treatment for periodontal disease, dental root form implants, or root canals. Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. If TMJ is caused by malocclusion, benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits |
YES | $45.00 |
$45.00 |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
Exclusions: Lab tests that are not ordered by a Doctor or Other Provider. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.816075508052652 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2025 |
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, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs |
EHB Percent of Total Premium | 1.0 |
First Tier Utilization | 100% |
Formulary ID | NCF005 |
Formulary URL | URL |
HIOS Product ID | 17414NC001 |
Import Date | 2024-10-11 01:02:00 |
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 | 17414 |
Issuer Marketplace Marketing Name | AmeriHealth Caritas Next |
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 | NCN001 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Accidental Injury and Emergency Only |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Accidental Injury and Emergency Only |
Plan Brochure | URL |
Plan Effective Date | 2025-01-01 |
Plan Expiration Date | 2025-12-31 |
Plan ID (Standard Component ID with Variant) | 17414NC0010014-00 |
Plan Marketing Name | AmeriHealth Caritas Next Gold Deluxe + No Referrals |
Plan Type | HMO |
Plan Variant Marketing Name | AmeriHealth Caritas Next Gold Deluxe + No Referrals |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $1,800 |
SBC Scenario, Having a Baby, Copayment | $70 |
SBC Scenario, Having a Baby, Deductible | $850 |
SBC Scenario, Having a Baby, Limit | $0 |
SBC Scenario, Having Diabetes, Coinsurance | $10 |
SBC Scenario, Having Diabetes, Copayment | $1,600 |
SBC Scenario, Having Diabetes, Deductible | $850 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $400 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $40 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $850 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | NCS001 |
Source Name | HIOS |
Plan ID | 17414NC0010014 |
State Code | NC |
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 | 20.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1700 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $850 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $850 |
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 | $15000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7500 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,500 |
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 | 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, 03 Dec 2024 06:24 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