Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision - 96992IN0060013 Health Insurance Plan

Aetna Health Inc. (a PA corp.) health insurance plan with the Plan ID 96992IN0060013. The plan is called Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.10% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.90% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 96992IN0060013
Health Insurance Plan Year 2025
State Indiana
Health Insurance Issuer Aetna Health Inc. (a PA corp.)
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 96992IN0060013-00
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 Indiana All US States
All 8081 23346
PCP 686 771
Allergy 3 4
OB/GYN 34 45
Dentists 1024 1169
Available Variants of the Health Plan

Standard Off Exchange Plan - 96992IN0060013-00

Standard On Exchange Plan - 96992IN0060013-01

Open to Indians below 300% FPL - 96992IN0060013-02

Open to Indians above 300% FPL - 96992IN0060013-03

Last Plan Update Date Thu, 26 Sep 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan, 96992IN0060013-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited

Per Indiana law, abortion only covered if performed because a woman becomes pregnant through an act of rape or incest; or an abortion is necessary to avert the pregnant woman?s death or a substantial and irreversible impairment of a major bodily function of the pregnant woman.

NO
Accidental Dental

Cost share driven by provider/setting.

YES

$35.00

100.00%
Acupuncture
NO
Allergy Testing

Cost share driven by provider/setting.

YES

$35.00

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult

Coverage is limited to ages 19 and up.?$50 deductible / $1,000 calendar year maximum for all dental services (Routine check-up, Basic & Major).

YES

50.00%

100.00%
Basic Dental Care - Child
NO
Chemotherapy

Cost share driven by provider/setting.

YES

40.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 12.0 Visit(s) per Year

Cost share driven by provider/setting.

YES

$15.00

100.00%
Cosmetic Surgery

Covered for reconstructive surgery.

NO
Delivery and All Inpatient Services for Maternity Care
YES

45.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Cost share driven by provider/setting.

YES

$35.00

100.00%
Dialysis

Cost share driven by provider/setting.

YES

40.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

One wig per year following cancer treatment.

YES

40.00% Coinsurance after deductible

100.00%
Emergency Room Services

Exclusions: No coverage for non-emergency use of the emergency room.

YES

45.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

45.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per year, through the end of the month in which the member turns 19.

YES

$10.00

100.00%
Gender Affirming Care
NO
Generic Drugs

Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.

YES

$3.00

100.00%
Habilitation Services

Health care services that are needed to keep, learn, or improve your skills and functioning for daily living which may include physical therapy, occupational therapy, and speech therapy. Please refer to the plan policy documents for detailed information. Cost share is driven by provider/setting.

YES

35.00% Coinsurance after deductible

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 100.0 Visit(s) per Year

Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home.

YES

$35.00

100.00%
Hospice Services

Cost share driven by provider/setting.

YES

45.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

35.00% Coinsurance after deductible

100.00%
Infertility Treatment

Coverage limited to diagnosis and treatment of the underlying medical condition. Cost share driven by provider/setting.

NO
Infusion Therapy

Cost share driven by provider/setting.

YES

40.00% Coinsurance after deductible

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

45.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

45.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

$25.00

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult

Coverage is limited to ages 19 and up. 6 month waiting period regardless of prior coverage. $50 deductible / $1,000 calendar year maximum for all dental services (Routine check-up, Basic & Major).

YES

50.00%

100.00%
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

45.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

YES

$15.00

100.00%
Non-Preferred Brand Drugs

Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.

YES

40.00% Coinsurance after deductible

100.00%
Nutritional Counseling

Cost share driven by provider/setting.

YES

No Charge

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

Cost share applies to both in-person and virtual services from in-network providers. Cost share does not apply to virtual services from designated telemedicine providers. If this is an HSA plan, deductible applies.

YES

$15.00

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

40.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Year

Coverage for Speech Therapy is limited to 20 visits per year, Occupational Therapy is limited to 20 visits per year, and Physical Therapy is limited to 20 visits per year. Benefit limits for rehabilitation and habilitation services are separate.

YES

$35.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.

YES

$40.00

100.00%
Prenatal and Postnatal Care

Member cost share applies to postnatal care.

YES

45.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization

Age and frequency schedules may apply.

YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

Cost share applies to both in-person and virtual services from in-network providers. Cost share does not apply to virtual services from designated telemedicine providers. If this is an HSA plan, deductible applies.

YES

$15.00

100.00%
Private-Duty Nursing

Limit: 82.0 Visit(s) per Year

Coverage is limited to 82 shifts per year.

YES

50.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

40.00% Coinsurance after deductible

100.00%
Radiation

Cost share driven by provider/setting.

YES

40.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Exclusions: Excludes all other reconstructive services that are not specifically outlined in Covered Services.

Cost share driven by provider/setting. Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed.

YES

45.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Year

Occupational Therapy is limited to 20 visits per Year, and Physical Therapy is limited to a separate 20 visits per year. Benefit limits for rehabilitation and habilitation services are separate.

YES

$35.00

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Coverage is limited to 20 visits per year. Benefit limits for rehabilitation and habilitation services are separate.

YES

$35.00

100.00%
Routine Dental Services (Adult)

Limit: 2.0 Visit(s) per Year

Coverage is limited to ages 19 and up. $1,000 calendar year maximum for all dental services (Routine check-up, Basic & Major).

YES

No Charge

100.00%
Routine Eye Exam (Adult)

Limit: 1.0 Exam(s) per Year

Coverage is limited to ages 19 and up. Benefit limitations may apply.

YES

$10.00

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

Coverage is limited to 1 exam every 12 months, through the end of the month in which the member turns 19.

YES

$10.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 90.0 Days per Year

YES

45.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$35.00

100.00%
Specialty Drugs

Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.

YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

45.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Cost share driven by provider/setting.

YES

$15.00

100.00%
Transplant

Cost share driven by provider/setting. Network benefits must be received within the Institutes of Excellence (IOE) transplant network.

YES

45.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Coverage includes diagnostic and surgical treatment of TMJ.

YES

$35.00

100.00%
Urgent Care Centers or Facilities

Exclusions: No coverage for non-urgent care.

YES

$25.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care

Age and frequency schedules may apply.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$50.00

100.00%

Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan Variant 96992IN0060013-00 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 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 Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
EHB Percent of Total Premium 0.9385
First Tier Utilization 100%
Formulary ID INF003
Formulary URL URL
HIOS Product ID 96992IN006
Import Date 2024-09-26 03:01:39
Limited Cost Sharing Plan Variation - Estimated Advanced Payment 0
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 Actuarial Value 78.10%
Issuer ID 96992
Issuer Marketplace Marketing Name Aetna CVS Health
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 INN001
Out of Country Coverage No
Out of Service Area Coverage No
Out of Service Area Coverage Description Except for Emergencies
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan ID (Standard Component ID with Variant) 96992IN0060013-00
Plan Marketing Name Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision
Plan Type HMO
Plan Variant Marketing Name Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $4,100
SBC Scenario, Having a Baby, Copayment $200
SBC Scenario, Having a Baby, Deductible $895
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
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 $500
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $895
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID INS001
Source Name HIOS
Plan ID 96992IN0060013
State Code IN
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $18390 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $9195 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $9,195
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $1790 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $895 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $895
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $1790 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $895 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $895
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 $18390 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9195 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,195
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 Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan, 96992IN0060013

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

Frequently Asked Questions(FAQ) about Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision, 96992IN0060013 Health Insurance Plan, 96992IN0060013

  • Does Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan, 96992IN0060013 support Mail Ordering?

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

  • Does (96992IN0060013) Health Insurance Plan, Variant (96992IN0060013-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does (96992IN0060013) Health Insurance Plan, Variant (96992IN0060013-00) have Out Of Country Coverage?

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

    Does (96992IN0060013) Health Insurance Plan, Variant (96992IN0060013-00) have Out of Service Area Coverage?

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

    Does (96992IN0060013) Health Insurance Plan, Variant (96992IN0060013-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan, Variant (96992IN0060013-00) offer Disease Management Programs for Asthma?

    Yes, the Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan Variant 96992IN0060013-00 offers Disease Management Program for Asthma.

    Does Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan, Variant (96992IN0060013-00) offer Disease Management Programs for Heart disease?

    Yes, the Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan Variant 96992IN0060013-00 offers Disease Management Program for Heart disease.

    Does Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan, Variant (96992IN0060013-00) offer Disease Management Programs for Depression?

    Yes, the Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan Variant 96992IN0060013-00 offers Disease Management Program for Depression.

    Does Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan, Variant (96992IN0060013-00) offer Disease Management Programs for Diabetes?

    Yes, the Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan Variant 96992IN0060013-00 offers Disease Management Program for Diabetes.

    Does Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan, Variant (96992IN0060013-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan Variant 96992IN0060013-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan, Variant (96992IN0060013-00) offer Disease Management Programs for Low back pain?

    Yes, the Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan Variant 96992IN0060013-00 offers Disease Management Program for Low back pain.

    Does Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan, Variant (96992IN0060013-00) offer Disease Management Programs for Pregnancy?

    Yes, the Gold 3 Advanced: Aetna network + $0 MinuteClinic + Adult Dental + Vision Health Insurance Plan Variant 96992IN0060013-00 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