AmeriHealth Caritas Florida, Inc. health insurance plan with the Plan ID 67926FL0010003. The plan is called AmeriHealth Caritas Next Silver Signature + No Referrals.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.01% (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 29.99% 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 | 67926FL0010003 | ||||||||||||||||||
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Health Insurance Plan Year | 2025 | ||||||||||||||||||
State | Florida | ||||||||||||||||||
Health Insurance Issuer | AmeriHealth Caritas Florida, Inc. | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 67926FL0010003-00 | ||||||||||||||||||
Provider Network(s) | PREFERRED | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 67926FL0010003-00 Standard On Exchange Plan - 67926FL0010003-01 Open to Indians below 300% FPL - 67926FL0010003-02 Open to Indians above 300% FPL - 67926FL0010003-03 73% AV Silver Plan - 67926FL0010003-04 |
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Last Plan Update Date | Sat, 12 Oct 2024 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 10 Dec 2024 06:32 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | $80.00 |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Bone Marrow Transplant
|
YES | 40.00% 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 | 40.00% Coinsurance after deductible |
100.00% |
Chemotherapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Child Health Supervision
Services must be covered from birth until age 16 and exempt from deductibles. Must receive periodic visits, appropriate immunizations, and laboratory tests. |
YES | No Charge |
100.00% |
Chiropractic Care
Limit: 35.0 Visit(s) per Benefit Period Exclusions: The following are specifically excluded from chiropractic care and osteopathic services: Charges for care not provided in an office setting, Chelation therapy, Maintenance or preventive treatment consisting of routine, long-term, or not medically necessary care provided to prevent reoccurrences or to maintain the patient?s current status, Manipulation under anesthesia, Services of a chiropractor or osteopath that are not within their scope of practice, as defined by state law, Vitamin or supplement therapy. Combined limit for all outpatient therapy plus chiropractic. Includes Massage Therapy and Spinal Manipulation. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Congenital Anomaly, including Cleft Lip/Palate
Coverage must include medical, dental, speech therapy, audiology, and nutrition services but only if these services are prescribed by the treating physician or surgeon and the physician or surgeon certifies that the services are medically necessary and consequent to treating the cleft lip or cleft palate. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Contraceptive Injections
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
Exclusions: Maternity services rendered to a covered person who is acting as a gestational surrogate are excluded and for services related to surrogate parenting Newborn must be covered for injury, sickness, or the cost of transporting the newborn to the nearest available facility that is appropriately stafffed. Coverage for transportation may not exceed the usual and customary charges, up to $1,000. Post partum assessment and newborn assessment must be performed. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Dental Anesthesia
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Care Management
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Diabetes Education
|
YES | No Charge |
100.00% |
Dialysis
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Enteral Formulas
Coverage required until the age of 25. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | 40.00% 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 | $20.00 |
100.00% |
Habilitation Services
Exclusions: For outpatient habilitative and rehabilitative services for which there is no reasonable expectation of acquiring, restoring, improving or maintaining a level of function 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 | $40.00 |
100.00% |
Hearing Aids
|
NO | ||
Home Health Care Services
Limit: 20.0 Days per Benefit Period Exclusions: Part-time- Services limited to less than 8 hours a day, less than 40 hours a week. Intermittent- Services limited to each visit up to but not exceeding 2 hours a day. Excluded: Services rendered by an employee/operator of an adult congregate living facility, adult foster home, adult day care center, or a nursing facility. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Hospice Services
|
YES | No Charge after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
NO | ||
Mammogram
Coverage for at least the following: (a)Baseline mammogram for any woman who is 35 or older, but younger than 40. (b) Mammogram every 2 years for any woman who is 40 or older, but younger than 50 or more frequently based on the patient's physician's recommendation. (c) A mammogram every year for any woman who is 50 or older. (d) One or more mammograms a year, based on a physician's recommendation for any woman who is at risk for breast cancer |
YES | No Charge |
100.00% |
Mastectomy
Includes post-mastectomy care. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
Exclusions: Excludes services for psychological testing associated with the evaluation and diagnosis of learning disabilities or for mental retardation. Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. |
YES | $40.00 |
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 | $80.00 Copay after deductible |
100.00% |
Nutritional Counseling
Diabetes coverage includes nutrition counseling; home health services include nutritional guidance. |
YES | No Charge |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Orthotic Devices
Exclusions: Expenses for arch supports, shoe inserts designed to effect conformational changes in the foot or foot alignment, orthopedic shoes, over-the-counter, custom-made or built-up shoes, cast shoes, sneakers, readymade compression hose or support hose, or similar type devices/appliances regardless of intended use, except for therapeutic shoes (including inserts and/or modifications) for the treatment of severe diabetic foot disease; Expenses for orthotic appliances or devices, which straighten or re-shape the conformation of the head or bones of the skull or cranium through cranial banding or molding (e.g. dynamic orthotic cranioplasty or molding helmets); except when the orthotic appliance or device is used as an alternative to an internal fixation device as a result of surgery for craniosynostosis; and Expenses for devices necessary to exercise, train, or participate in sports. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Osteoporosis
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $40.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $40.00 |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 40.00% 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 | $40.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
Preventive Care/Screening/Immunization
|
YES | 0.00% |
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 | $40.00 |
100.00% |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
|
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 | 40.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
Only for Breast reconstruction following a Mastectomy. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Benefit Period Exclusions: If provided in an Inpatient setting, member must be able to actively participate in 2 rehabilitative therapies and be able to tolerate at least 3 hours per day of skilled Rehab services for at least 5 days a week. Member?s condition must be likely to significantly improve. Inpatient rehab limit is 21 days. Combined limit for all outpatient therapy plus chiropractic. |
YES | $40.00 |
100.00% |
Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $40.00 |
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 | 40.00% Coinsurance after deductible |
100.00% |
Routine Foot Care
|
YES | $80.00 |
100.00% |
Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period |
YES | 40.00% 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 | $80.00 |
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 | $350.00 Copay after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. |
YES | $40.00 |
100.00% |
Transplant
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
YES | 40.00% 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 | $60.00 |
$60.00 |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.7001186159724491 |
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 Silver Off Exchange Plan |
Dental Only Plan | No |
Design Type | Design 1 |
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 | FLF003 |
Formulary URL | URL |
HIOS Product ID | 67926FL001 |
Import Date | 2024-10-12 01:01:36 |
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 | 67926 |
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 | Silver |
Multiple In Network Tiers | No |
National Network | No |
Network ID | FLN001 |
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) | 67926FL0010003-00 |
Plan Marketing Name | AmeriHealth Caritas Next Silver Signature + No Referrals |
Plan Type | HMO |
Plan Variant Marketing Name | AmeriHealth Caritas Next Silver Signature + No Referrals |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $2,000 |
SBC Scenario, Having a Baby, Copayment | $70 |
SBC Scenario, Having a Baby, Deductible | $5,000 |
SBC Scenario, Having a Baby, Limit | $0 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $1,100 |
SBC Scenario, Having Diabetes, Deductible | $900 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,300 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | FLS001 |
Source Name | HIOS |
Plan ID | 67926FL0010003 |
State Code | FL |
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 | 40.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $10000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,000 |
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 | $16000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,000 |
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 | 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, 10 Dec 2024 06:32 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