Gold 80 HMO 250/35 + Child Dental - 40513CA0400049 Health Insurance Plan
Kaiser Foundation Health Plan, Inc. health insurance plan with the Plan ID 40513CA0400049. The plan is called Gold 80 HMO 250/35 + Child Dental.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.56% (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 18.44% 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 | 40513CA0400049 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | California | ||||||||||||||||||
| Health Insurance Issuer | Kaiser Foundation Health Plan, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 40513CA0400049-01 | ||||||||||||||||||
| Provider Network(s) | ['CAN001'] | ||||||||||||||||||
| 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 | |||||||||||||||||||
| Last Plan Update Date | Mon, 17 Apr 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Gold 80 HMO 250/35 + Child Dental Health Insurance Plan Variant 40513CA0400049-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.81557677 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| First Tier Utilization | 100% |
| Formulary ID | CAF018 |
| HIOS Product ID | 40513CA040 |
| HSA/HRA Employer Contribution | No |
| Import Date | 4/17/2023 |
| Inpatient Copayment Maximum Days | 5 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer ID | 40513 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $250 per person | $500 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $250 |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | CAN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 40513CA0400049-01 |
| Plan Marketing Name | Gold 80 HMO 250/35 + Child Dental |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold 80 HMO 250/35 + Child Dental |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $800 |
| SBC Scenario, Having a Baby, Deductible | $250 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $1,200 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $10 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $800 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $250 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | CAS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All |
| Specialty Drug Maximum Coinsurance | $250 |
| Plan ID | 40513CA0400049 |
| State Code | CA |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $7800 per person | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Gold 80 HMO 250/35 + Child Dental Health Insurance Plan, 40513CA0400049
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Gold 80 HMO 250/35 + Child Dental, 40513CA0400049 Health Insurance Plan, 40513CA0400049
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Does Gold 80 HMO 250/35 + Child Dental Health Insurance Plan, 40513CA0400049 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (40513CA0400049) Health Insurance Plan, Variant (40513CA0400049-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (40513CA0400049) Health Insurance Plan, Variant (40513CA0400049-01) have Out of Service Area Coverage?
No, unfortunately there
is no Out of Service Area Coverage for this Health Insurance
Plan (variant of plan).
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