Clear Gold - 62505OK0120017 Health Insurance Plan

Celtic Insurance Company health insurance plan with the Plan ID 62505OK0120017. The plan is called Clear Gold.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.79% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.21% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.36% (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 20.64% 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 62505OK0120017
Health Insurance Plan Year 2023
State Oklahoma
Health Insurance Issuer Celtic Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 62505OK0120017-01
Provider Network(s) ['OKN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT).

Providers Oklahoma All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 62505OK0120017-00

Standard On Exchange Plan - 62505OK0120017-01

Open to Indians below 300% FPL - 62505OK0120017-02

Open to Indians above 300% FPL - 62505OK0120017-03

Last Plan Update Date Fri, 24 Feb 2023 00:00 GMT
Last Import Date Tue, 22 Oct 2024 06:47 GMT

Benefits of Clear Gold Health Insurance Plan, 62505OK0120017-01

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing

Issuer clarifies this is a covered benefit but stipulated under the Medical Policy and not written in the member materials.

YES

$60.00

50.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chiropractic Care
YES

$60.00

50.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dental Check-Up for Children
NO
Diabetes Education
YES

$60.00

50.00% Coinsurance after deductible
Dialysis
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Durable Medical Equipment
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Room Services
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

OON: Up to $50 for frames, $37.50 for lenses and $91 for contacts in lieu of eyeglasses. See EOC for lens limits.

YES

No Charge

No Charge
Gender Affirming Care
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Generic Drugs

Most Ambetter Plans offer Preferred Generic Drugs at $5 or less. Please see plan's Summary of Benefits and Coverage (SBC) or policy document for Preferred Generic and Generic prescription drug cost.

YES

$13.80

100.00%
Habilitation Services

Limit: 25.0 Visit(s) per Benefit Period

YES

$35.00

50.00% Coinsurance after deductible
Hearing Aids

Limit: 2.0 Item(s) per Benefit Period

Hearing aid devices limited to one per ear, every 48 months.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Home Health Care Services

Limit: 30.0 Visit(s) per Benefit Period

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Hospice Services
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)

Cost share is based on place of service.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infertility Treatment
NO
Infusion Therapy

Limit: 25.0 Visit(s) per Benefit Period

Covered under Outpatient Therapy Services.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services

Cost share is based on place of service.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Emergency Room
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Mental/Behavioral Health Emergency Transportation/Ambulance
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Mental/Behavioral Health ER Physician Fee
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services

Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Other Services
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services

Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism.

YES

$25.00

50.00% Coinsurance after deductible
Mental/Behavioral Health Urgent Care
YES

$60.00

50.00%
Non-Preferred Brand Drugs
YES

50.00% Coinsurance after deductible

100.00%
Nutritional Counseling

Diabetes self-management training and training related to medical nutrition therapy.

YES

$60.00

50.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$25.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Outpatient Rehabilitation Services

Limit: 30.0 Days per Benefit Period

YES

$35.00

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preferred Brand Drugs
YES

$40.00

100.00%
Prenatal and Postnatal Care
YES

$25.00

50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

No Charge

50.00%
Primary Care Visit to Treat an Injury or Illness

Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge.

YES

$25.00

50.00% Coinsurance after deductible
Private-Duty Nursing

Limit: 85.0 Visit(s) per Benefit Period

Pre-authorization required.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Prosthetic Devices
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Radiation
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Reconstructive Surgery

Breast reconstruction or implantation or removal of breast prostheses is a Covered Service only when performed solely and directly as a result of mastectomy which is Medically Necessary.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 25.0 Visit(s) per Benefit Period

Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined).

YES

$35.00

50.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Limit: 25.0 Visit(s) per Benefit Period

Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined).

YES

$35.00

50.00% Coinsurance after deductible
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

Up to $38.50 OON

YES

No Charge

No Charge
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Benefit Period

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Specialist Visit
YES

$60.00

50.00% Coinsurance after deductible
Specialty Drugs
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services

Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism.

YES

$25.00

50.00% Coinsurance after deductible
Substance Use Disorder Emergency Room
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Substance Use Disorder Emergency Transportation/Ambulance
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Substance Use Disorder ER Physician Fee
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Substance Use Disorder Outpatient Other Services
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Use Disorder Urgent Care
YES

$60.00

50.00%
Transplant
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$60.00

50.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

50.00%
X-rays and Diagnostic Imaging

Cost share is based on place of service.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible

Clear Gold Health Insurance Plan Variant 62505OK0120017-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.79363902
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Gold On Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID OKF009
Formulary URL URL
HIOS Product ID 62505OK012
Import Date 2/24/2023 1:01
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 Yes
Is a Referral Required for Specialist? No
Issuer Actuarial Value 78.79%
Issuer ID 62505
Issuer Marketplace Marketing Name Ambetter of Oklahoma
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 OKN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 62505OK0120017-01
Plan Marketing Name Clear Gold
Plan Type PPO
Plan Variant Marketing Name Clear Gold
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,700
SBC Scenario, Having a Baby, Copayment $40
SBC Scenario, Having a Baby, Deductible $900
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,000
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $400
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $900
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID OKS001
Source Name HIOS
Plan ID 62505OK0120017
State Code OK
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 $7200 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $3600 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $3,600
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 $1800 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $900 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $900
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $5400 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $2700 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $2,700
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
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 Clear Gold Health Insurance Plan, 62505OK0120017

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

Frequently Asked Questions(FAQ) about Clear Gold, 62505OK0120017 Health Insurance Plan, 62505OK0120017

  • Does Clear Gold Health Insurance Plan, 62505OK0120017 support Mail Ordering?

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

  • Does (62505OK0120017) Health Insurance Plan, Variant (62505OK0120017-01) offer Disease Management Programs?

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

    Does (62505OK0120017) Health Insurance Plan, Variant (62505OK0120017-01) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (62505OK0120017) Health Insurance Plan, Variant (62505OK0120017-01) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

    Does (62505OK0120017) Health Insurance Plan, Variant (62505OK0120017-01) offer Disease Management Programs?

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

    Does Clear Gold Health Insurance Plan, Variant (62505OK0120017-01) offer Disease Management Programs for Asthma?

    Yes, the Clear Gold Health Insurance Plan Variant 62505OK0120017-01 offers Disease Management Program for Asthma.

    Does Clear Gold Health Insurance Plan, Variant (62505OK0120017-01) offer Disease Management Programs for Heart disease?

    Yes, the Clear Gold Health Insurance Plan Variant 62505OK0120017-01 offers Disease Management Program for Heart disease.

    Does Clear Gold Health Insurance Plan, Variant (62505OK0120017-01) offer Disease Management Programs for Diabetes?

    Yes, the Clear Gold Health Insurance Plan Variant 62505OK0120017-01 offers Disease Management Program for Diabetes.

    Does Clear Gold Health Insurance Plan, Variant (62505OK0120017-01) offer Disease Management Programs for Pregnancy?

    Yes, the Clear Gold Health Insurance Plan Variant 62505OK0120017-01 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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