CommunityCare Gold L21 - 98905OK0130041 Health Insurance Plan
CommunityCare HMO Inc. health insurance plan with the Plan ID 98905OK0130041. The plan is called CommunityCare Gold L21.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.06% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.94% 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 78.03% (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 21.97% 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 | 98905OK0130041 | ||||||||||||||||||
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| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Oklahoma | ||||||||||||||||||
| Health Insurance Issuer | CommunityCare HMO Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 98905OK0130041-00 | ||||||||||||||||||
| Provider Network(s) | PREFFERED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 17 Jun 2025 12:51 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 98905OK0130041-00 Standard On Exchange Plan - 98905OK0130041-01 |
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| Last Plan Update Date | Tue, 22 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 17 Jun 2025 12:51 GMT |
CommunityCare Gold L21 Health Insurance Plan Variant 98905OK0130041-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7803169064071479 |
| 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 | Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pain Management |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | OKF030 |
| Formulary URL | URL |
| HIOS Product ID | 98905OK013 |
| Import Date | 2024-10-22 01:01:28 |
| 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 Actuarial Value | 78.06% |
| Issuer ID | 98905 |
| Issuer Marketplace Marketing Name | CommunityCare |
| 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 | Yes |
| Out of Country Coverage Description | Emergency Services |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 98905OK0130041-00 |
| Plan Marketing Name | CommunityCare Gold L21 |
| Plan Type | HMO |
| Plan Variant Marketing Name | CommunityCare Gold L21 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,800 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $3,800 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $90 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $90 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,300 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OKS001 |
| Source Name | HIOS |
| Plan ID | 98905OK0130041 |
| 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 | 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 | $12000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3800 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,800 |
| 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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of CommunityCare Gold L21 Health Insurance Plan, 98905OK0130041
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about CommunityCare Gold L21, 98905OK0130041 Health Insurance Plan, 98905OK0130041
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Does CommunityCare Gold L21 Health Insurance Plan, 98905OK0130041 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (98905OK0130041) Health Insurance Plan, Variant (98905OK0130041-00) offer Disease Management Programs?
Does (98905OK0130041) Health Insurance Plan, Variant (98905OK0130041-00) have Out Of Country Coverage?
Does (98905OK0130041) Health Insurance Plan, Variant (98905OK0130041-00) have Out of Service Area Coverage?
Does (98905OK0130041) Health Insurance Plan, Variant (98905OK0130041-00) offer Disease Management Programs?
Does CommunityCare Gold L21 Health Insurance Plan, Variant (98905OK0130041-00) offer Disease Management Programs for Heart disease?
Does CommunityCare Gold L21 Health Insurance Plan, Variant (98905OK0130041-00) offer Disease Management Programs for Diabetes?
Does CommunityCare Gold L21 Health Insurance Plan, Variant (98905OK0130041-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Disclaimer: This is based on the import(Date: Tue, 17 Jun 2025 12:51 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