Elite Gold - 61604LA0010018 Health Insurance Plan
Louisiana Healthcare Connections Inc. health insurance plan with the Plan ID 61604LA0010018. The plan is called Elite Gold.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.75% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.25% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 61604LA0010018 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Louisiana | ||||||||||||||||||
| Health Insurance Issuer | Louisiana Healthcare Connections Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 61604LA0010018-00 | ||||||||||||||||||
| Provider Network(s) | ['LAN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 61604LA0010018-00 Standard On Exchange Plan - 61604LA0010018-01 |
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| Last Plan Update Date | Fri, 24 Feb 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Elite Gold Health Insurance Plan, 61604LA0010018-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $200.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $60.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
High-dose chemotherapy to support transplant procedures. |
YES | $200.00 |
100.00% |
| Chiropractic Care
|
YES | $60.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 30.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Diabetic Self-Management/Diabetic Education is subject to applicable deductible, coinsurance & copayment amounts; member's cost share shall not exceed more than $500 dollars for a one time evaluation and training program. Additional Diabetes Self-Management/Diabetic Education, if medically necessary because of a significant change in a member's symptoms or conditions, is also covered; member's cost share shall not exceed more than $100 dollars per year. |
YES | $60.00 |
100.00% |
| Dialysis
|
YES | $200.00 |
100.00% |
| Durable Medical Equipment
Medical Foods/Low protein food products for the treatment of inherited metabolic diseases are subject to applicable deductible, coinsurance & copayment amounts; member's cost share shall not exceed more than $200 dollars per month. |
YES | 30.00% |
100.00% |
| Emergency Room Services
|
YES | 30.00% |
30.00% |
| Emergency Transportation/Ambulance
Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | 30.00% |
30.00% |
| Eye Glasses for Children
|
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | 30.00% |
100.00% |
| 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
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 | $50.00 |
100.00% |
| Hearing Aids
Limit: 2.0 Item(s) per 3 Years |
YES | 30.00% |
100.00% |
| Home Health Care Services
Home Health Care services provided to a Member in lieu of an Inpatient Hospital Admission are covered; must obtain authorization. |
YES | 30.00% |
100.00% |
| Hospice Services
|
YES | 30.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Cost share is based on place of service. |
YES | $75.00 |
100.00% |
| Infertility Treatment
Coverage is available for diagnosis and services required to correct underlying medical causes of infertility. |
NO | ||
| Infusion Therapy
|
YES | $200.00 |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 30.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 30.00% |
100.00% |
| Laboratory Outpatient and Professional Services
Cost share is based on place of service. |
YES | $40.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
Long Term Acute Care is a covered benefit. Long Term Nursing Care/ Custodial Care is not a covered benefit. |
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Emergency Room
|
YES | 30.00% |
30.00% |
| Mental/Behavioral Health Emergency Transportation/Ambulance
|
YES | 30.00% |
30.00% |
| Mental/Behavioral Health ER Physician Fee
|
YES | 30.00% |
30.00% |
| Mental/Behavioral Health Inpatient Services
Inpatient treatment for mental/behavioral health disorders must be Authorized as provided in the Care Management Article of this Benefit Plan. |
YES | 30.00% |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
|
YES | $200.00 |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $5.00 |
100.00% |
| Mental/Behavioral Health Urgent Care
|
YES | $35.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% |
100.00% |
| Nutritional Counseling
Coverage only for diabetes education. |
YES | $60.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $5.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $200.00 |
100.00% |
| Outpatient Rehabilitation Services
|
YES | $50.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $200.00 |
100.00% |
| Preferred Brand Drugs
|
YES | $50.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $5.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge |
YES | $5.00 |
100.00% |
| Private-Duty Nursing
|
YES | 30.00% |
100.00% |
| Prosthetic Devices
|
YES | 30.00% |
100.00% |
| Radiation
|
YES | $200.00 |
100.00% |
| Reconstructive Surgery
|
YES | 30.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | $50.00 |
100.00% |
| Rehabilitative Speech Therapy
|
YES | $50.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
|
YES | No Charge |
100.00% |
| Routine Foot Care
Coverage is limited to diabetes care only. |
NO | ||
| Skilled Nursing Facility
|
YES | 30.00% |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
Limited to copayment or coinsurance applicable to specialty tiered drug amount not to exceed one hundred and fifty dollars per month for each drug up to a thirty-day supply, after deductible is met). |
YES | 50.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
Inpatient treatment for substance abuse must be Authorized as provided in the Care Management Article of this Benefit Plan, when coverage for alcohol and/or drug abuse is provided. |
YES | 30.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
Covered Services will be only those, which are for treatment for abuse of alcohol, drugs or other chemicals, and the resultant physiological and/or psychological dependency, which develops with continued use. |
YES | $5.00 |
100.00% |
| Substance Use Disorder Emergency Room
|
YES | 30.00% |
30.00% |
| Substance Use Disorder Emergency Transportation/Ambulance
|
YES | 30.00% |
30.00% |
| Substance Use Disorder ER Physician Fee
|
YES | 30.00% |
30.00% |
| Substance Use Disorder Outpatient Other Services
|
YES | $200.00 |
100.00% |
| Substance Use Disorder Urgent Care
|
YES | $35.00 |
100.00% |
| Transplant
Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | 30.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $35.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Cost share is based on place of service. |
YES | $75.00 |
100.00% |
Elite Gold Health Insurance Plan Variant 61604LA0010018-00 Attributes
| Plan Attribute | Value |
|---|---|
| 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 Off 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 | LAF010 |
| Formulary URL | URL |
| HIOS Product ID | 61604LA001 |
| 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 | 81.75% |
| Issuer ID | 61604 |
| Issuer Marketplace Marketing Name | Ambetter from Louisiana Healthcare Connections |
| 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 | LAN001 |
| 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) | 61604LA0010018-00 |
| Plan Marketing Name | Elite Gold |
| Plan Type | HMO |
| Plan Variant Marketing Name | Elite Gold |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,500 |
| SBC Scenario, Having a Baby, Copayment | $600 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $200 |
| SBC Scenario, Having Diabetes, Copayment | $1,100 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | LAS001 |
| Source Name | HIOS |
| Plan ID | 61604LA0010018 |
| State Code | LA |
| 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 | 30.00% |
| 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 | $10000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,000 |
| 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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Elite Gold Health Insurance Plan, 61604LA0010018
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Elite Gold, 61604LA0010018 Health Insurance Plan, 61604LA0010018
-
Does Elite Gold Health Insurance Plan, 61604LA0010018 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (61604LA0010018) Health Insurance Plan, Variant (61604LA0010018-00) offer Disease Management Programs?
Does (61604LA0010018) Health Insurance Plan, Variant (61604LA0010018-00) have Out Of Country Coverage?
Does (61604LA0010018) Health Insurance Plan, Variant (61604LA0010018-00) have Out of Service Area Coverage?
Does (61604LA0010018) Health Insurance Plan, Variant (61604LA0010018-00) offer Disease Management Programs?
Does Elite Gold Health Insurance Plan, Variant (61604LA0010018-00) offer Disease Management Programs for Asthma?
Does Elite Gold Health Insurance Plan, Variant (61604LA0010018-00) offer Disease Management Programs for Heart disease?
Does Elite Gold Health Insurance Plan, Variant (61604LA0010018-00) offer Disease Management Programs for Diabetes?
Does Elite Gold Health Insurance Plan, Variant (61604LA0010018-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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