Standard Gold 2000 - 67243LA0090045 Health Insurance Plan

Vantage Health Plan, Inc. health insurance plan with the Plan ID 67243LA0090045. The plan is called Standard Gold 2000.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.02% (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 21.98% 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 67243LA0090045
Health Insurance Plan Year 2023
State Louisiana
Health Insurance Issuer Vantage Health Plan, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 67243LA0090045-00
Provider Network(s) ['LAN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Louisiana All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 67243LA0090045-00

Standard On Exchange Plan - 67243LA0090045-01

Open to Indians below 300% FPL - 67243LA0090045-02

Open to Indians above 300% FPL - 67243LA0090045-03

Last Plan Update Date Thu, 18 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Standard Gold 2000 Health Insurance Plan, 67243LA0090045-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult

An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care.

YES

No Charge

No Charge
Basic Dental Care - Child
YES

50.00%

50.00%
Chemotherapy
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chiropractic Care
YES

$30.00

50.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Minimum stay of 48 hours

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Year

YES

No Charge

No Charge
Diabetes Education
YES

$30.00

50.00% Coinsurance after deductible
Dialysis
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Durable Medical Equipment

Various limitations apply as stated in the Benchmark plan.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Room Services

The ER Copay is waived if the visit results in an inpatient admission.

YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Air ambulance services are covered in only specified situations.

YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Visit(s) per Year

YES

50.00%

50.00% Coinsurance after deductible
Gender Affirming Care
NO
Generic Drugs

Quantity limits, authorizations and step therapy limits may apply.

YES

$15.00

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

$30.00

50.00% Coinsurance after deductible
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
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

25.00% Coinsurance after deductible

100.00%
Hospice Services
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infertility Treatment
NO
Infusion Therapy
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)

Copays, if applicable, are per day for first three days only.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services

Lab services in the Emergency Room are subject to the deductible, if applicable.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult

An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care.

YES

No Charge

No Charge
Major Dental Care - Child
YES

50.00%

50.00%
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

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
YES

$30.00

50.00% Coinsurance after deductible
Non-Preferred Brand Drugs

Quantity limits, authorizations and step therapy limits may apply.

YES

$60.00

100.00%
Nutritional Counseling

Limit: 4.0 Visit(s) per Benefit Period

Coverage only for diabetes education.

YES

$30.00

50.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child

Medically Necessary orthodontia only.

YES

50.00%

50.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)

Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization.

YES

$30.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Outpatient Rehabilitation Services
YES

$30.00

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preferred Brand Drugs

Quantity limits, authorizations and step therapy limits may apply.

YES

$30.00

100.00%
Prenatal and Postnatal Care
YES

$30.00

50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization

Quantitative limit units apply, see Benchmark plan.

YES

0.00%

50.00%
Primary Care Visit to Treat an Injury or Illness

Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization.

YES

$30.00

50.00% Coinsurance after deductible
Private-Duty Nursing

Limit: 150.0 Hours per Benefit Period

Inpatient private-duty nursing services are not covered.

YES

50.00% Coinsurance after deductible

100.00%
Prosthetic Devices

Various limitations apply as stated in the Benchmark plan.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Radiation
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Reconstructive Surgery

Plan only outlines benefits for breast reconstruction. Must be medically necessary and related to mastectomy.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Rehabilitative Occupational and Physical Therapies are included in the Outpatient Rehabilitation Services benefit listed in Line 91 above.

YES

$30.00

50.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Rehabilitative Speech Therapy is included in the Outpatient Rehabilitation Services benefit listed in Line 91 above.

YES

$30.00

50.00% Coinsurance after deductible
Routine Dental Services (Adult)

Limit: 2.0 Visit(s) per Year

Covers exam and cleaning

YES

No Charge

No Charge
Routine Eye Exam (Adult)

Limit: 1.0 Visit(s) per Year

An added benefit

YES

$60.00

50.00% Coinsurance after deductible
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

$60.00

50.00% Coinsurance after deductible
Routine Foot Care
YES

No Charge

50.00%
Skilled Nursing Facility

Three-day prior inpatient stay

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Specialist Visit

Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization.

YES

$60.00

50.00% Coinsurance after deductible
Specialty Drugs

Specialty drugs may be limited to a thirty (30) day supply. Quantity limits, authorizations and step therapy limits may apply.

YES

$100.00

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

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
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

$30.00

50.00% Coinsurance after deductible
Transplant

Exclusions: Non-EHB and out-of-network transplant services

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$45.00

50.00% Coinsurance after deductible
Weight Loss Programs

Exclusions: Non-Vantage Weight Loss programs are excluded.

Vantage Weight Loss programs are covered as part of the Vantage Wellness Program.

YES

No Charge

100.00%
Well Baby Visits and Care
YES

0.00%

50.00%
X-rays and Diagnostic Imaging
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible

Standard Gold 2000 Health Insurance Plan Variant 67243LA0090045-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.780221363
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 Design 2
Disease Management Programs Offered Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Weight Loss Programs
EHB Percent of Total Premium 0.976658
First Tier Utilization 100%
Formulary ID LAF001
Formulary URL URL
HIOS Product ID 67243LA009
Import Date 8/18/2022 1:00
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 No
Is a Referral Required for Specialist? No
Issuer ID 67243
Issuer Marketplace Marketing Name Vantage Health Plan
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 Yes
Out of Country Coverage Description Limited to Emergency Services only. Covered as in-network.
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Out-of-Network Deductible and Co-insurance
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 67243LA0090045-00
Plan Marketing Name Standard Gold 2000
Plan Type POS
Plan Variant Marketing Name Standard Gold 2000
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,000
SBC Scenario, Having a Baby, Copayment $40
SBC Scenario, Having a Baby, Deductible $2,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $900
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $10
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,000
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID LAS001
Source Name HIOS
Plan ID 67243LA0090045
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 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $4000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $2000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $2,000
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $15000 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 $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
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 No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of Standard Gold 2000 Health Insurance Plan, 67243LA0090045

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

Frequently Asked Questions(FAQ) about Standard Gold 2000, 67243LA0090045 Health Insurance Plan, 67243LA0090045

  • Does Standard Gold 2000 Health Insurance Plan, 67243LA0090045 support Mail Ordering?

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

  • Does (67243LA0090045) Health Insurance Plan, Variant (67243LA0090045-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Weight Loss Programs

    Does (67243LA0090045) Health Insurance Plan, Variant (67243LA0090045-00) have Out Of Country Coverage?

    Yes. Details: Limited to Emergency Services only. Covered as in-network.

    Does (67243LA0090045) Health Insurance Plan, Variant (67243LA0090045-00) have Out of Service Area Coverage?

    Yes. Details: Out-of-Network Deductible and Co-insurance

    Does (67243LA0090045) Health Insurance Plan, Variant (67243LA0090045-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Weight Loss Programs

    Does Standard Gold 2000 Health Insurance Plan, Variant (67243LA0090045-00) offer Disease Management Programs for Heart disease?

    Yes, the Standard Gold 2000 Health Insurance Plan Variant 67243LA0090045-00 offers Disease Management Program for Heart disease.

    Does Standard Gold 2000 Health Insurance Plan, Variant (67243LA0090045-00) offer Disease Management Programs for Depression?

    Yes, the Standard Gold 2000 Health Insurance Plan Variant 67243LA0090045-00 offers Disease Management Program for Depression.

    Does Standard Gold 2000 Health Insurance Plan, Variant (67243LA0090045-00) offer Disease Management Programs for Diabetes?

    Yes, the Standard Gold 2000 Health Insurance Plan Variant 67243LA0090045-00 offers Disease Management Program for Diabetes.

    Does Standard Gold 2000 Health Insurance Plan, Variant (67243LA0090045-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Standard Gold 2000 Health Insurance Plan Variant 67243LA0090045-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Standard Gold 2000 Health Insurance Plan, Variant (67243LA0090045-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Standard Gold 2000 Health Insurance Plan Variant 67243LA0090045-00 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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