SoloCare Bronze No Referral HMO (+ Dental) 110017 - 83761GA0110017 Health Insurance Plan
Alliant Health Plans health insurance plan with the Plan ID 83761GA0110017. The plan is called SoloCare Bronze No Referral HMO (+ Dental) 110017.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.36% (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 35.64% 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 | 83761GA0110017 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 83761GA0110017-00 | ||||||||||||||||||
| Provider Network(s) | ['GAN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Apr 2024 06:19 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 83761GA0110017-00 Standard On Exchange Plan - 83761GA0110017-01 |
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| Last Plan Update Date | Tue, 14 Mar 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Apr 2024 06:19 GMT |
Benefits of SoloCare Bronze No Referral HMO (+ Dental) 110017 Health Insurance Plan, 83761GA0110017-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
Exclusions: $1,000 Annual Benefit Maximum; services not covered for cosmetic care |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Child
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
|
NO | ||
| Cosmetic Surgery
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Procedure(s) per Year |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Diabetes Education
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| 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 |
100.00% |
| 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 |
100.00% |
| Generic Drugs
Exclusions: Excludes infertility services including medications. |
YES | $30.00 |
$30.00 |
| 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% Coinsurance after deductible |
100.00% |
| 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 |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Insulin infusion devices. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | No Charge |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
Exclusions: $1,000 Annual Benefit Maximum; services not covered for cosmetic care |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Major Dental Care - Child
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| 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% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: Excludes infertility services including medications. |
YES | $225.00 |
$225.00 |
| Nutritional Counseling
Limit: 4.0 Visit(s) per Year |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
Exclusions: $1,000 Annual Benefit Maximum; services not covered for cosmetic care |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Child
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| 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% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: Excludes infertility services including medications. |
YES | $200.00 |
$200.00 |
| Prenatal and Postnatal Care
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| 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 | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 40.0 Visit(s) per Year |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
Exclusions: $1,000 Annual Benefit Maximum; services not covered for cosmetic care |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | 40.00% Coinsurance after deductible |
100.00% |
| 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 |
100.00% |
| Specialist Visit
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Specialty Drugs
Exclusions: Excludes infertility services including medications. |
YES | $250.00 |
$250.00 |
| Substance Abuse Disorder Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| 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% Coinsurance after deductible |
100.00% |
| 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 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Weight Loss Programs
Limit: 4.0 Visit(s) per Year |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Well Baby Visits and Care
Care provided for birth through age 5. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 40.00% Coinsurance after deductible |
100.00% |
SoloCare Bronze No Referral HMO (+ Dental) 110017-00 Health Insurance Plan Variant 83761GA0110017-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.643569374 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
| 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 Bronze Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Diabetes |
| EHB Percent of Total Premium | 0.9614 |
| First Tier Utilization | 100% |
| Formulary ID | GAF011 |
| Formulary URL | URL |
| HIOS Product ID | 83761GA011 |
| 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 | Existing |
| 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 | Expanded Bronze |
| 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) | 83761GA0110017-00 |
| Plan Level Exclusions | No |
| Plan Marketing Name | SoloCare Bronze No Referral HMO (+ Dental) 110017 |
| Plan Type | HMO |
| Plan Variant Marketing Name | SoloCare Bronze No Referral HMO (+ Dental) 110017-00 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $500 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $8,250 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $2,800 |
| SBC Scenario, Having Diabetes, Deductible | $1,600 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $10 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,400 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | GAS017 |
| Source Name | HIOS |
| Plan ID | 83761GA0110017 |
| 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 | 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 | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $17000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $8500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $8,500 |
| 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 | $18000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,000 |
| 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 Bronze No Referral HMO (+ Dental) 110017 Health Insurance Plan, 83761GA0110017
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about SoloCare Bronze No Referral HMO (+ Dental) 110017, 83761GA0110017 Health Insurance Plan, 83761GA0110017
-
Does SoloCare Bronze No Referral HMO (+ Dental) 110017 Health Insurance Plan, 83761GA0110017 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (83761GA0110017) Health Insurance Plan, Variant (83761GA0110017-00) offer Disease Management Programs?
Does (83761GA0110017) Health Insurance Plan, Variant (83761GA0110017-00) have Out Of Country Coverage?
Does (83761GA0110017) Health Insurance Plan, Variant (83761GA0110017-00) have Out of Service Area Coverage?
Does (83761GA0110017) Health Insurance Plan, Variant (83761GA0110017-00) offer Disease Management Programs?
Does SoloCare Bronze No Referral HMO (+ Dental) 110017-00 Health Insurance Plan, Variant (83761GA0110017-00) offer Disease Management Programs for Asthma?
Does SoloCare Bronze No Referral HMO (+ Dental) 110017-00 Health Insurance Plan, Variant (83761GA0110017-00) offer Disease Management Programs for Diabetes?
Disclaimer: This is based on the import(Date: Tue, 16 Apr 2024 06:19 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