SoloCare PPO Silver Standardized - 83761GA0040379 Health Insurance Plan

Alliant Health Plans health insurance plan with the Plan ID 83761GA0040379. The plan is called SoloCare PPO Silver Standardized.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.06% (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 29.94% 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 83761GA0040379
Health Insurance Plan Year 2023
State Georgia
Health Insurance Issuer Alliant Health Plans
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 83761GA0040379-00
Provider Network(s) ['GAN001']
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 Georgia 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 - 83761GA0040379-00

Standard On Exchange Plan - 83761GA0040379-01

Open to Indians below 300% FPL - 83761GA0040379-02

Open to Indians above 300% FPL - 83761GA0040379-03

73% AV Silver Plan - 83761GA0040379-04

87% AV Silver Plan - 83761GA0040379-05

94% AV Silver Plan - 83761GA0040379-06

Last Plan Update Date Tue, 14 Mar 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of SoloCare PPO Silver Standardized Health Insurance Plan, 83761GA0040379-00

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

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Chiropractic Care
NO
Cosmetic Surgery
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 2.0 Procedure(s) per Year

NO
Diabetes Education
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Dialysis
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Durable Medical Equipment
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Emergency Room Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Gender Affirming Care

AHP will cover Gender-Affirming Care that is deemed medically necessary through a review of clinical documentation provided as part of our utilization management processes

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Generic Drugs

Exclusions: Excludes infertility services including medications.

YES

$20.00

$20.00
Habilitation Services

Limit: 40.0 Visit(s) per Year

Exclusions: Hypnotherapy; Excluded forms of therapy include, but are not limited to, vestibular rehabilitation, primal therapy, chelation therapy, rolfing, psychodrama, megavitamin therapy, purging, bioenergetics therapy, cognitive therapy, electromagnetic therapy, vision perception training (orthoptics), salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, actinic changes and/or which are performed as a treatment for acne, services and supplies for smoking cessation programs and treatment of nicotine addiction, and carbon dioxide. Self-Help - Biofeedback, recreational, educational or sleep therapy or other forms of self-care or self-help training and any related diagnostic testing.

Habilitation is classified the same as Rehabilitation under medical/surgical benefits not mental health/substance abuse.

YES

$40.00

40.00% Coinsurance after deductible
Hearing Aids
NO
Home Health Care Services

Limit: 120.0 Visit(s) per Year

Exclusions: Covered services for Home Health do not include: Food, housing, homemaker services, sitters, home-delivered meals; Home Health Care Services which are not Medically Necessary or of a non-skilled level of care. Services of a person who ordinarily resides in the patient's home or is a member of the family of either the patient or the patient's spouse. Any services for any period during with the Member is not under the continuing care of a PHysician, Convalescent or Custodial Care where the Member has spent a period of time recovery of an illness or surgery and where skilled care is not required or the services being rendered are only for aid in daily living, i.e., for the convenience of the patient. Any services or supplies not specifically listed as Covered Services. Routine care and/or examination of a newborn child. Dietician services. Maintenance therapy. Dialysis treatment. Purchase or rental of dialysis equipment. Private duty nursing care.

Medical treatment provided in the home on a part time or intermittent basis including visits by a licensed health care professional, including a nurse, therpaist, or home health aide; and physical speech, and occupational therapy. When these therapy services are provided as part of home health they are not subject to separate visit limits for therapy services.

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Hospice Services

Exclusions: Hospice care covered expenses do not include: A confinement not required for acute pain control or other treatment for an acute phase of chronic symptom management.

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Infertility Treatment
NO
Infusion Therapy

Insulin infusion devices.

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services

Services are sub-classified as office visit and all other intensive outpatient therapy and partial hospitalization programs are subject to coinsurance.

YES

$40.00

40.00% Coinsurance after deductible
Non-Preferred Brand Drugs

Exclusions: Excludes infertility services including medications.

YES

$80.00 Copay after deductible

$80.00 Copay after deductible
Nutritional Counseling

Limit: 4.0 Visit(s) per Year

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$40.00

40.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Outpatient Rehabilitation Services

Limit: 40.0 Visit(s) per Year

Exclusions: Hypnotherapy; Excluded forms of therapy include, but are not limited to, vestibular rehabilitation, primal therapy, chelation therapy, rolfing, psychodrama, megavitamin therapy, purging, bioenergetics therapy, cognitive therapy, electromagnetic therapy, vision perception training (orthoptics), salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, actinic changes and/or which are performed as a treatment for acne, services and supplies for smoking cessation programs and treatment of nicotine addiction, and carbon dioxide. Self-Help - Biofeedback, recreational, educational or sleep therapy or other forms of self-care or self-help training and any related diagnostic testing.

YES

$40.00

40.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Preferred Brand Drugs

Exclusions: Excludes infertility services including medications.

YES

$40.00

$40.00
Prenatal and Postnatal Care
YES

$40.00

40.00% Coinsurance after deductible
Preventive Care/Screening/Immunization

The recommendations by the USPSTF for breast cancer screenings, mammography and preventions issued prior to November 2009 will be considered current. Immunizations covered are those recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC).

YES

0.00%

40.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness
YES

$40.00

40.00% Coinsurance after deductible
Private-Duty Nursing
NO
Prosthetic Devices
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Radiation
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Reconstructive Surgery
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Year

YES

$40.00

40.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Limit: 40.0 Visit(s) per Year

YES

$40.00

40.00% 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

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Year

Beneifts will not be provided when: A Member reaches the maximum level of recovery possible and no longer requires other than routine care; Care is primarily Custodial Care, not requiring definitive medical or 24-hour-a-day nursing service; Care is for chronic brain syndromes for which no specific medical conditions exist that require care in a Skilled Nursing Faciliy; A Member is undergoing senile deterioration, mental deficiency or retardation, and has no medical condition requiring care; The care rendered is for other than Skilled Convalescent Care.

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Specialist Visit
YES

$80.00

40.00% Coinsurance after deductible
Specialty Drugs

Exclusions: Excludes infertility services including medications.

YES

$350.00 Copay after deductible

$350.00 Copay after deductible
Substance Abuse Disorder Inpatient Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services

Services are sub-classified as office visit and all other intensive outpatient therapy and partial hospitalization programs are subject to coinsurance.

YES

$40.00

40.00% Coinsurance after deductible
Transplant

Limit: 10000.0 Dollars per Procedure

Limited to a combined maximum of $10,000 per covered organ transplant.

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Urgent Care Centers or Facilities
YES

$60.00

40.00% Coinsurance after deductible
Weight Loss Programs

Limit: 4.0 Visit(s) per Year

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Well Baby Visits and Care

Care provided for birth through age 5.

YES

0.00%

40.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible

SoloCare PPO Silver Standardized 40379-00 Health Insurance Plan Variant 83761GA0040379-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.700578499
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 Silver Off Exchange Plan
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Diabetes
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID GAF019
Formulary URL URL
HIOS Product ID 83761GA004
Import Date 3/14/2023 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 No
Is a Referral Required for Specialist? No
Issuer ID 83761
Issuer Marketplace Marketing Name Alliant Health Plans
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID GAN001
Out of Country Coverage No
Out of Country Coverage Description Coverage is available for emergency situations
Out of Service Area Coverage No
Out of Service Area Coverage Description In-Network providers available in certain Tennessee counties that border Georgia. Verify participating providers at AlliantPlans.com
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 83761GA0040379-00
Plan Marketing Name SoloCare PPO Silver Standardized
Plan Type PPO
Plan Variant Marketing Name SoloCare PPO Silver Standardized 40379-00
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,700
SBC Scenario, Having a Baby, Copayment $50
SBC Scenario, Having a Baby, Deductible $5,800
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,100
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $400
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,700
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID GAS015
Source Name HIOS
Plan ID 83761GA0040379
State Code GA
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 $51600 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $25800 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $25,800
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 $11600 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5800 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,800
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $40000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $20000 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $20,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $17800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,900
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 No

Copay & Coinsurance of SoloCare PPO Silver Standardized Health Insurance Plan, 83761GA0040379

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

Frequently Asked Questions(FAQ) about SoloCare PPO Silver Standardized, 83761GA0040379 Health Insurance Plan, 83761GA0040379

  • Does SoloCare PPO Silver Standardized Health Insurance Plan, 83761GA0040379 support Mail Ordering?

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

  • Does (83761GA0040379) Health Insurance Plan, Variant (83761GA0040379-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Diabetes

    Does (83761GA0040379) Health Insurance Plan, Variant (83761GA0040379-00) have Out Of Country Coverage?

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

    Does (83761GA0040379) Health Insurance Plan, Variant (83761GA0040379-00) 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: In-Network providers available in certain Tennessee counties that border Georgia. Verify participating providers at AlliantPlans.com

    Does (83761GA0040379) Health Insurance Plan, Variant (83761GA0040379-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Diabetes

    Does SoloCare PPO Silver Standardized 40379-00 Health Insurance Plan, Variant (83761GA0040379-00) offer Disease Management Programs for Asthma?

    Yes, the SoloCare PPO Silver Standardized 40379-00 Health Insurance Plan Variant 83761GA0040379-00 offers Disease Management Program for Asthma.

    Does SoloCare PPO Silver Standardized 40379-00 Health Insurance Plan, Variant (83761GA0040379-00) offer Disease Management Programs for Diabetes?

    Yes, the SoloCare PPO Silver Standardized 40379-00 Health Insurance Plan Variant 83761GA0040379-00 offers Disease Management Program for Diabetes.

 

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