Elite Gold (QualChoiceLife) - 37903AR0070031 Health Insurance Plan
QualChoice Life & Health Insurance Company, Inc. health insurance plan with the Plan ID 37903AR0070031. The plan is called Elite Gold (QualChoiceLife).
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).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.75% (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 18.25% 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 | 37903AR0070031 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Arkansas | ||||||||||||||||||
| Health Insurance Issuer | QualChoice Life & Health Insurance Company, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 37903AR0070031-00 | ||||||||||||||||||
| Provider Network(s) | ['ARN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 May 2024 06:08 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 37903AR0070031-00 Standard On Exchange Plan - 37903AR0070031-01 |
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| Last Plan Update Date | Tue, 25 Oct 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Benefits of Elite Gold (QualChoiceLife) Health Insurance Plan, 37903AR0070031-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $200.00 |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $60.00 |
50.00% |
| Applied Behavior Analysis Based Therapies
Person with diagnosis of serious mental or physical condition; Person certified by a PCP to have significant behavioral problem. Prior authorization may be required - please contact the number listed on your ID card. |
YES | $200.00 |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Cardiac Rehabilitation
Limit: 36.0 Visit(s) per Year Prior authorization may be required - please contact the number listed on your ID card. |
YES | $50.00 |
50.00% Coinsurance after deductible |
| Chemotherapy
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $200.00 |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Combined 30 visit limit per year for Chiropractic Care, PT, OT and ST. |
YES | $60.00 |
50.00% |
| Cochlear Implants
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Craniofacial Surgery
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Dental Anesthesia
|
YES | $200.00 |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
Covered based on medical necessity. Prior authorization may be required - please contact the number listed on your ID card. |
YES | $60.00 |
50.00% |
| Diabetes Education
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $60.00 |
50.00% |
| Dialysis
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $200.00 |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | 30.00% |
30.00% |
| Emergency Transportation/Ambulance
Prior authorization may be required for Air transport - please contact the number listed on your ID card. |
YES | 30.00% |
30.00% |
| 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 |
| Gastric Electrical Stimulation
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Gender Affirming Care
|
YES | 30.00% |
50.00% Coinsurance after deductible |
| Generic Drugs
Prior authorization may be required - please contact the number listed on your ID card. 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: 30.0 Visit(s) per Year 30 visits per year for outpatient habilatative services. 180 visits per year for developmental services. Prior authorization may be required - please contact the number on your ID card. |
YES | $50.00 |
50.00% Coinsurance after deductible |
| Hearing Aids
Limit: 2.0 Item(s) per 3 Years 1 pair every 3 years. Prior authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
50.00% |
| Home Health Care Services
Limit: 50.0 Visit(s) per Year Prior authorization may be required - please contact the number listed on your ID card. Coverage is provided for Home Health Services when Coverage Policy supports the need for in-home service and such care is prescribed or ordered by a Physician. Covered Services must be provided through and billed by a licensed home health agency. Covered Services provided in the home include services of a Registered Professional Nurse (R.N.), a Licensed Practical Nurse (L.P.N.) or a Licensed Psychiatric Technical Nurse (L.P.T.N.). |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Hospice Services
Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less. |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $75.00 |
50.00% Coinsurance after deductible |
| Infertility Treatment
See policy for details |
YES | $200.00 |
50.00% Coinsurance after deductible |
| Infusion Therapy
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $200.00 |
50.00% Coinsurance after deductible |
| Inherited Metabolic Disorder - PKU
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $40.00 |
50.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $40.00 |
50.00% |
| 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% |
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
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Other Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $200.00 |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
Prior authorization may be required - please contact the number listed on your ID card. (PCP and Other Practitioner visits do not require Prior Authorization) |
YES | $5.00 |
50.00% |
| Mental/Behavioral Health Urgent Care
|
YES | $35.00 |
50.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% |
100.00% |
| Nutritional Counseling
When provided in conjunction with Diabetic Self-Management Training, for services needed by Members in connection with cleft palate management and for nutritional assessment programs provided in and by a Hospital. Prior authorization may be required - please contact the number listed on your id card. |
YES | $60.00 |
50.00% |
| Off Label Prescription Drugs
|
YES | 50.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $5.00 |
50.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $200.00 |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Prior authorization may be required - please contact the number listed on your ID card. (PCP and Other Practitioner visits do not require Prior Authorization) (Including Speech. Occupational, and Physical Therapy). Combined 30 visit limit per year for PT, OT, ST and Chiropractic Care. |
YES | $50.00 |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $200.00 |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
|
YES | $50.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $5.00 |
50.00% |
| Preventative Drugs
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
50.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $5.00 |
50.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Radiation
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $200.00 |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality... 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year 60 inpatient days/year. 30 visit limit is combined with PT, OT, speech and Chiropractic Care. Prior authorization may be required - please contact the number on your ID card. |
YES | $50.00 |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Combined 30 visit limit per year for PT, OT, ST and Chiropractic Care. Prior authorization may be required - please contact the number on your ID card. |
YES | $50.00 |
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
Prior authorization may be required. Covered no limit. |
YES | $60.00 |
50.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Year 60 days per year in a facility. Prior authorization may be required - please contact the number listed on you ID card. |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $60.00 |
50.00% |
| Specialty Drugs
|
YES | 50.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
Prior authorization may be required - please contact the number listed on your ID card. (PCP and Other Practitioner visits do not require Prior Authorization) |
YES | $5.00 |
50.00% |
| 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
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $200.00 |
50.00% Coinsurance after deductible |
| Substance Use Disorder Urgent Care
|
YES | $35.00 |
50.00% |
| Transplant
Prior authorization may be required - please contact the number listed on your ID card. |
YES | 30.00% |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $200.00 |
50.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
|
YES | $35.00 |
50.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
50.00% |
| Well Child Care
|
YES | No Charge |
50.00% |
| X-rays and Diagnostic Imaging
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $75.00 |
50.00% Coinsurance after deductible |
Elite Gold (QualChoiceLife) Health Insurance Plan Variant 37903AR0070031-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.817503152 |
| 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 | 0.9999826 |
| First Tier Utilization | 100% |
| Formulary ID | ARF003 |
| Formulary URL | URL |
| HIOS Product ID | 37903AR007 |
| Import Date | 10/25/2022 20:01 |
| 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 | 37903 |
| Issuer Marketplace Marketing Name | Ambetter from Arkansas Health & Wellness |
| 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 | ARN001 |
| 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) | 37903AR0070031-00 |
| Plan Marketing Name | Elite Gold (QualChoiceLife) |
| Plan Type | PPO |
| Plan Variant Marketing Name | Elite Gold (QualChoiceLife) |
| 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 | ARS001 |
| Source Name | SERFF |
| Plan ID | 37903AR0070031 |
| State Code | AR |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $30000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $15000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $15,000 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $10000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $5000 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $5,000 |
| 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 | $10000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $5000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $5,000 |
| 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 | $20000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $10000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $10,000 |
| 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 (QualChoiceLife) Health Insurance Plan, 37903AR0070031
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Elite Gold (QualChoiceLife), 37903AR0070031 Health Insurance Plan, 37903AR0070031
-
Does Elite Gold (QualChoiceLife) Health Insurance Plan, 37903AR0070031 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (37903AR0070031) Health Insurance Plan, Variant (37903AR0070031-00) offer Disease Management Programs?
Does (37903AR0070031) Health Insurance Plan, Variant (37903AR0070031-00) have Out Of Country Coverage?
Does (37903AR0070031) Health Insurance Plan, Variant (37903AR0070031-00) have Out of Service Area Coverage?
Does (37903AR0070031) Health Insurance Plan, Variant (37903AR0070031-00) offer Disease Management Programs?
Does Elite Gold (QualChoiceLife) Health Insurance Plan, Variant (37903AR0070031-00) offer Disease Management Programs for Asthma?
Does Elite Gold (QualChoiceLife) Health Insurance Plan, Variant (37903AR0070031-00) offer Disease Management Programs for Heart disease?
Does Elite Gold (QualChoiceLife) Health Insurance Plan, Variant (37903AR0070031-00) offer Disease Management Programs for Diabetes?
Does Elite Gold (QualChoiceLife) Health Insurance Plan, Variant (37903AR0070031-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 07 May 2024 06:08 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