Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options) - 11718TX0140022 Health Insurance Plan

Community Health Choice Texas, Inc. health insurance plan with the Plan ID 11718TX0140022. The plan is called Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 11718TX0140022
Health Insurance Plan Year 2025
State Texas
Health Insurance Issuer Community Health Choice Texas, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 11718TX0140022-02
Provider Network(s) NON-PREFERRED 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 Texas All US States
All 2932 3040
PCP 452 475
Allergy N/A N/A
OB/GYN 46 48
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 11718TX0140022-00

Standard On Exchange Plan - 11718TX0140022-01

Open to Indians below 300% FPL - 11718TX0140022-02

Open to Indians above 300% FPL - 11718TX0140022-03

Last Plan Update Date Sat, 28 Sep 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options) Health Insurance Plan, 11718TX0140022-02

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

Cost sharing and limitation depend on type and site of service. Limited to treatment for a Dental Injury to a Sound Natural Tooth.

YES

$0.00

100.00%
Acupuncture
NO
Allergy Testing

Cost sharing depends on type and site of service.

YES

$0.00

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy

Cost sharing and limitation depend on type and site of service. Injectable chemotherapeutic agents require preauthorization.

YES

$0.00

100.00%
Chiropractic Care

Limit: 35.0 Visit(s) per Year

Limited to combined 35 visits per year, including Chiropractic.

YES

$0.00

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.

YES

0.00%

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Cost sharing depends on type and site of service.

YES

$0.00

100.00%
Dialysis

Cost sharing depends on type and site of service.

YES

$0.00

100.00%
Durable Medical Equipment

Certain services require preauthorization (DME over $500).

YES

0.00%

100.00%
Emergency Room Services
YES

0.00%

0.00%
Emergency Transportation/Ambulance

Exclusions: Travel or ambulance services for convenience.

Prior authorization required for out of network ambulance services, out of area transfers, non-emergency ground transportation, air transportation, and facility to facility transfers.

YES

$0.00

$0.00
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

For select frames, standard lenses, and contact lenses only.

YES

$0.00

100.00%
Gender Affirming Care
NO
Generic Drugs

Subject to formulary requirements and preauthorization may be required (when generic is not the preferred agent).

YES

$0.00

100.00%
Habilitation Services

Cost sharing depends on type and site of service. Limited to medical necessity. Prior authorization is required.

YES

$0.00

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

To restore or correction of impaired speech or hearing loss. Each ear, every three years. Prior authorization is required.

YES

0.00%

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

Prior Authorization is required.

YES

$0.00

100.00%
Hospice Services

Cost sharing and limitations depend on type and site of service.

YES

$0.00

100.00%
Imaging (CT/PET Scans, MRIs)

Preauthorization is required.

YES

0.00%

100.00%
Infertility Treatment
NO
Infusion Therapy

Cost sharing and limitation depend on type and site of service. Preauthorization is required.

YES

$0.00

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.

YES

0.00%

100.00%
Inpatient Physician and Surgical Services

Prior Authorization is required for inpatient surgical services.

YES

$0.00

100.00%
Laboratory Outpatient and Professional Services

Some services require preauthorization.

YES

$0.00

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

0.00%

100.00%
Mental/Behavioral Health Outpatient Services

Certain services require preauthorization. Cost sharing depends on type and site of service. This benefit (Mental/Behavioral Health Outpatient Services, Substance Abuse Disorder Outpatient Services, and Habilitation Services) is subject to different cost-sharing depending on whether the service is an office visit or other outpatient service. Office visits are subject to copays, while facility-based services are subject to coinsurance.

YES

$0.00

100.00%
Non-Preferred Brand Drugs

Subject to formulary requirements and preauthorization may be required.

YES

$0.00

100.00%
Nutritional Counseling

Preauthorization is required. Cost sharing depends on type and site of service.

YES

$0.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)

Cost sharing and limitations depend on type and site of service.

YES

$0.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

Cost sharing and limitations depend on the type and site of service. Preauthorization is required for outpatient surgeries.

YES

0.00%

100.00%
Outpatient Rehabilitation Services

Limited to Medically Necessary outpatient Rehabilitative Therapy visits to or by a Participating Provider other than a Primary Care Physician. Prior authorization is required.

YES

$0.00

100.00%
Outpatient Surgery Physician/Surgical Services

Outpatient services and Habilitation Services are subject to different cost-sharing depending on whether the service is an office visit or other outpatient service. Office visits are subject to copays, while facility-based services are subject to coinsurance. Preauthorization is required for outpatient surgeries.

YES

0.00%

100.00%
Preferred Brand Drugs

Subject to formulary requirements and preauthorization may be required.

YES

$0.00

100.00%
Prenatal and Postnatal Care
YES

$0.00

100.00%
Preventive Care/Screening/Immunization
YES

$0.00

100.00%
Primary Care Visit to Treat an Injury or Illness

$0 24/7 Virtual Care Options available under select plans for care received from a virtual provider for primary care services. Cost sharing for primary care services received from an in-person provider may cost more. Please see the Plan Brochure associated with this plan for more information on this benefit.

YES

$0.00

100.00%
Private-Duty Nursing

Inpatient private duty nursing.

YES

$0.00

100.00%
Prosthetic Devices

Medically necessary foot orthotics are not subject to a calendar year maximum. Preauthorization is required.

YES

0.00%

100.00%
Radiation

Cost sharing and limitation depend on type and site of service. Proton beam radiation requires preauthorization.

YES

$0.00

100.00%
Reconstructive Surgery

Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. Preauthorization is required. Cost sharing depends on type and site of service.

YES

0.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Prior Authorization is required. Limited to medical necessity.

YES

$0.00

100.00%
Rehabilitative Speech Therapy

Prior Authorization is required. Limited to medical necessity.

YES

$0.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

Covered services for children 18 and under.

YES

$0.00

100.00%
Routine Foot Care

Coverage for foot care is limited to members with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency is covered. Any services or supplies in connection with routine foot care, including the removal of warts, corns, or calluses, or the cutting and trimming of toenails in the absence of diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency are excluded. Cost sharing and limitations depend on site of service.

YES

$0.00

100.00%
Skilled Nursing Facility

Limit: 25.0 Days per Year

Cost sharing and limitation depend on type and site of service. Prior authorization is required.

YES

0.00%

100.00%
Specialist Visit
YES

$0.00

100.00%
Specialty Drugs

Subject to formulary requirements and preauthorization may be required.

YES

0.00%

100.00%
Substance Abuse Disorder Inpatient Services

Preauthorization is required.

YES

0.00%

100.00%
Substance Abuse Disorder Outpatient Services

Certain services require preauthorization. Cost sharing depends on type and site of service. This benefit (Mental/Behavioral Health Outpatient Services, Substance Abuse Disorder Outpatient Services, and Habilitation Services) is subject to different cost-sharing depending on whether the service is an office visit or other outpatient service. Office visits are subject to copays, while facility-based services are subject to coinsurance.

YES

$0.00

100.00%
Transplant

Exclusions: Subject to the conditions described below, benefits for covered services and supplies provided to a Participant by a Hospital, Physician, or Other Provider related to an organ or tissue transplant will be determined as follows, but only if all the following conditions are met: The transplant procedure is not Experimental/Investigational in nature; and Donated human organs or tissue or an FDA-approved artificial device are used; and The recipient is a Participant under the Plan; and The transplant procedure is preauthorized as required under the Plan; and The Participant meets all of the criteria established by CHC in pertinent written medical policies; and The Participant meets all of the protocols established by the Hospital in which the transplant is performed. Donor expenses for a Participant in connection with an organ or tissue transplant is not a covered benefit if the recipient is not covered under this Plan. No benefits are available for any organ or tissue transplant procedure, or services performed in preparation for, or in conjunction with, such procedure, which CHC considers to be Experimental/Investigational.

Preauthorization is required. Cost sharing and limitation depend on type and site of service.

YES

0.00%

100.00%
Treatment for Temporomandibular Joint Disorders

Prior authorization required for temporomandibular joint surgery.

YES

$0.00

100.00%
Urgent Care Centers or Facilities

$0 24/7 Virtual Care Options available under select plans for care received from a virtual provider for primary care services. Cost sharing for primary care services received from an in-person provider may cost more. Please see the Plan Brochure associated with this plan for more information on this benefit.

YES

$0.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

$0.00

100.00%
X-rays and Diagnostic Imaging

Prior Authorization is required.

YES

$0.00

100.00%

Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options) Health Insurance Plan Variant 11718TX0140022-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1.0
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 Zero Cost Sharing Plan Variation
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID TXF001
Formulary URL URL
HIOS Product ID 11718TX014
Import Date 2024-09-28 01:02:16
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 11718
Issuer Marketplace Marketing Name Community Health Choice
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 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 11718TX0140022-02
Plan Marketing Name Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options)
Plan Type HMO
Plan Variant Marketing Name Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
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 $0
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 $0
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 11718TX0140022
State Code TX
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $0
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $0
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
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 $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $0
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 Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options) Health Insurance Plan, 11718TX0140022

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

Frequently Asked Questions(FAQ) about Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options), 11718TX0140022 Health Insurance Plan, 11718TX0140022

  • Does Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options) Health Insurance Plan, 11718TX0140022 support Mail Ordering?

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

  • Does (11718TX0140022) Health Insurance Plan, Variant (11718TX0140022-02) offer Disease Management Programs?

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

    Does (11718TX0140022) Health Insurance Plan, Variant (11718TX0140022-02) have Out Of Country Coverage?

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

    Does (11718TX0140022) Health Insurance Plan, Variant (11718TX0140022-02) 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 (11718TX0140022) Health Insurance Plan, Variant (11718TX0140022-02) offer Disease Management Programs?

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

    Does Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options) Health Insurance Plan, Variant (11718TX0140022-02) offer Disease Management Programs for Asthma?

    Yes, the Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options) Health Insurance Plan Variant 11718TX0140022-02 offers Disease Management Program for Asthma.

    Does Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options) Health Insurance Plan, Variant (11718TX0140022-02) offer Disease Management Programs for Heart disease?

    Yes, the Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options) Health Insurance Plan Variant 11718TX0140022-02 offers Disease Management Program for Heart disease.

    Does Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options) Health Insurance Plan, Variant (11718TX0140022-02) offer Disease Management Programs for Diabetes?

    Yes, the Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options) Health Insurance Plan Variant 11718TX0140022-02 offers Disease Management Program for Diabetes.

    Does Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options) Health Insurance Plan, Variant (11718TX0140022-02) offer Disease Management Programs for Pregnancy?

    Yes, the Community Ultra Select Gold 022 (No Deductible for PCP, Specialists & Generics, $0 PCP 24/7 Virtual Care Options) Health Insurance Plan Variant 11718TX0140022-02 offers Disease Management Program for Pregnancy.

 

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