AmeriHealth Caritas Next Silver Signature + No Referrals - 67926FL0010003 Health Insurance Plan

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
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).

Providers Florida All US States
All 5191 5343
PCP 1043 1080
Allergy 5 5
OB/GYN 47 52
Dentists 4 4
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

87% AV Silver Plan - 67926FL0010003-05

94% AV Silver Plan - 67926FL0010003-06

Last Plan Update Date Sat, 12 Oct 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan, 67926FL0010003-00

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%

AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan Variant 67926FL0010003-00 Attributes

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

Copay & Coinsurance of AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan, 67926FL0010003

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about AmeriHealth Caritas Next Silver Signature + No Referrals, 67926FL0010003 Health Insurance Plan, 67926FL0010003

  • Does AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan, 67926FL0010003 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (67926FL0010003) Health Insurance Plan, Variant (67926FL0010003-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs

    Does (67926FL0010003) Health Insurance Plan, Variant (67926FL0010003-00) have Out Of Country Coverage?

    Yes. Details: Accidental Injury and Emergency Only

    Does (67926FL0010003) Health Insurance Plan, Variant (67926FL0010003-00) have Out of Service Area Coverage?

    Yes. Details: Accidental Injury and Emergency Only

    Does (67926FL0010003) Health Insurance Plan, Variant (67926FL0010003-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs

    Does AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan, Variant (67926FL0010003-00) offer Disease Management Programs for Asthma?

    Yes, the AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan Variant 67926FL0010003-00 offers Disease Management Program for Asthma.

    Does AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan, Variant (67926FL0010003-00) offer Disease Management Programs for Heart disease?

    Yes, the AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan Variant 67926FL0010003-00 offers Disease Management Program for Heart disease.

    Does AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan, Variant (67926FL0010003-00) offer Disease Management Programs for Depression?

    Yes, the AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan Variant 67926FL0010003-00 offers Disease Management Program for Depression.

    Does AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan, Variant (67926FL0010003-00) offer Disease Management Programs for Diabetes?

    Yes, the AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan Variant 67926FL0010003-00 offers Disease Management Program for Diabetes.

    Does AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan, Variant (67926FL0010003-00) offer Disease Management Programs for Pregnancy?

    Yes, the AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan Variant 67926FL0010003-00 offers Disease Management Program for Pregnancy.

    Does AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan, Variant (67926FL0010003-00) offer Disease Management Programs for Weight loss programs?

    Yes, the AmeriHealth Caritas Next Silver Signature + No Referrals Health Insurance Plan Variant 67926FL0010003-00 offers Disease Management Program for Weight loss programs.

 

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