AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards - 17414NC0010009 Health Insurance Plan

AmeriHealth Caritas North Carolina, Inc. health insurance plan with the Plan ID 17414NC0010009. The plan is called AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.00% (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 22.00% 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 17414NC0010009
Health Insurance Plan Year 2023
State North Carolina
Health Insurance Issuer AmeriHealth Caritas North Carolina, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 17414NC0010009-00
Provider Network(s) ['NCN001']
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 North Carolina 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 - 17414NC0010009-00

Standard On Exchange Plan - 17414NC0010009-01

Open to Indians below 300% FPL - 17414NC0010009-02

Open to Indians above 300% FPL - 17414NC0010009-03

Last Plan Update Date Wed, 01 Mar 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards Health Insurance Plan, 17414NC0010009-00

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

Exclusions: Excludes injury related to chewing or biting.

YES

25.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

25.00% Coinsurance after deductible

100.00%
Anesthetics
YES

25.00% Coinsurance after deductible

100.00%
Bariatric Surgery

Exclusions: Excludes removal of excess skin from the abdomen, arms or thighs. Any costs associated with membership in a weight management program. Drugs indicated for the short-term treatment of clinical obesity.

For surgical treatment of morbid obesity. Before pursuing bariatric surgery, a complete nutritional, behavioral, and medical evaluation must be completed, and requirements must be met. Bariatric surgery must be medically necessary to be eligible for coverage.

YES

25.00% Coinsurance after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Blood and Blood Services

We will cover the cost of the collection or obtainment of blood or blood products from a blood donor, including the Member in the case of autologous blood donation. We will cover the cost of transfusions of blood, plasma, blood plasma expanders and other fluids injected into the bloodstream. Benefits are provided for the cost of storing a Member?s own blood only when it is stored and used for a previously scheduled procedure.

YES

25.00% Coinsurance after deductible

100.00%
Cardiac Rehabilitation

Limit: 30.0 Visit(s) per Year

More available beyond the initial allotment if deemed medically necessary.

YES

25.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

25.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 30.0 Visit(s) per Benefit Period

30 visit limits for PT and OT combined (including chiropractic).

YES

25.00% Coinsurance after deductible

100.00%
Clinical Trials
YES

25.00% Coinsurance after deductible

100.00%
Congenital Anomaly, including Cleft Lip/Palate
YES

25.00% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Exclusions: Dependent children not covered for abortion

Abortion services available for first 16 weeks of pregnancy.

YES

25.00% Coinsurance after deductible

100.00%
Dental Anesthesia
YES

25.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Care Management

Includes routine foot care

YES

25.00% Coinsurance after deductible

100.00%
Diabetes Education
YES

25.00% Coinsurance after deductible

100.00%
Diagnosis and Treatment of Lymphedema

Exclusions: Over-the-counter compression or elastic knee-high or other stocking products.

YES

25.00% Coinsurance after deductible

100.00%
Dialysis
YES

25.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Exclusions: Appliances and accessories that serve no medical purpose or that are primarily for comfort or convenience; repair or replacement of equipment due to abuse or desire for new equipment.

YES

25.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Exclusions: Excludes services provided primarily for the convenience of travel, transportation to or from a doctor's office or dialysis center, transportation for the purpose of receiving services that are not considered "covered services.?

YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

25.00% Coinsurance after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs

Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document.

Certain off-label uses of cancer drugs will be covered in accordance with state law.

YES

$15.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Benefit Period

Exclusions: Cognitive Therapy. Group classes for pulmonary rehabilitation.

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

YES

25.00% Coinsurance after deductible

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

One hearing aid per hearing impaired ear, and replacement hearing aids for members under the age of 22. Once every 36 months.

YES

25.00% Coinsurance after deductible

100.00%
Home Health Care Services

Exclusions: Excludes homemaker services, such as cooking and housekeeping; Dietitian services or meals; Services that are provided by a close relative or a member of the household

YES

25.00% Coinsurance after deductible

100.00%
Hospice Services

Exclusions: Excludes homemaker services, such as cooking, housekeeping, and food or meal preparation.

Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.

YES

25.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)

Exclusions: Lab tests that are not ordered by Doctor of Other Provider

YES

25.00% Coinsurance after deductible

100.00%
Infertility Treatment

Limit: 3.0 Treatment(s) per Lifetime

Exclusions: Artificial insemination, in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and services for procurement and storage of donor semen/eggs are not covered

Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member. The lifetime maximums are described inmedical policies, which are guides considered when making coverage determinations.

YES

25.00% Coinsurance after deductible

100.00%
Infusion Therapy
YES

25.00% Coinsurance after deductible

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

Exclusions: Admissions primarily for the purpose of receiving diagnostic services or a physical examination; admissions primarily for the purpose of receiving therapy services, except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therapy.

YES

25.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services

Exclusions: Lab tests that are not ordered by a Doctor or Other Provider.

YES

25.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

Exclusions: Excludes, "Inpatient confinements that are primarily intended as a change of environment"; Counseling with relatives of a patient.

YES

25.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Exclusions: Excludes counseling with relatives about a patient.

Includes biofeedback.

YES

$30.00

100.00%
Non-Preferred Brand Drugs

Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document.

Certain off-label uses of cancer drugs will be covered in accordance with state law.

YES

$60.00

100.00%
Nutritional Counseling

Nutritional counseling visits are separate from the obesity-related office visits.

YES

No Charge

100.00%
Organ Donor Search

If a transplant is provided from a living donor to the recipient MEMBER who will receive the transplant: Benefits are provided for reasonable and necessary services related to the search for a donor. Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient's coverage.

YES

25.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Orthotic Devices for Positional Plagiocephaly
YES

25.00% Coinsurance after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$30.00

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

25.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Benefit Period

Exclusions: Applied Behavior Analysis (ABA) therapy; Cognitive therapy; Speech therapy for stammering or stuttering; Group classes for pulmonary rehabilitation; music therapy, remedial reading, recreational or activity therapy, all forms or special education and supplies or equipment used similarly; maintenance therapy; massage therapy.

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

YES

25.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document.

Certain off-label uses of cancer drugs will be covered in accordance with state law.

YES

$30.00

100.00%
Prenatal and Postnatal Care
YES

25.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization

All preventive care that is not state mandated is not covered OON.

YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$30.00

100.00%
Private-Duty Nursing

Exclusions: Excludes services provided by a close relative or a member of the household.

YES

25.00% Coinsurance after deductible

100.00%
Prosthetic Devices

Exclusions: Dental appliances except when medically necessary for the treatment of temporomandibular joint disease or obstructive sleep apnea; cosmetic improvements, such as implants of hair follicles and skin tone enhancements; lenses for keratoconus or any other eye procedure except as specifically covered under the health plan.

Prosthetic appliance must replace all or part of a body part or its function. Therapeutic contact lenses may be covered when used as a corneal bandage for a medical condition; benefits include a one-time replacement of eyeglass or contact lenses due to a prescription change following cataract surgery.

YES

25.00% Coinsurance after deductible

100.00%
Pulmonary Rehabilitation

Limit: 1.0 Treatment(s) per Year

YES

25.00% Coinsurance after deductible

100.00%
Radiation
YES

25.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy.

YES

25.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Benefit Period

Exclusions: Charges for care not provided in an office setting. Infusion therapy or chelation therapy. Services of a chiropractor or osteopath that are not within their scope of practice, as defined by state law.

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

YES

$30.00

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Benefit Period

Exclusions: Excludes speech therapy for stammering or stuttering

YES

$30.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Benefit Period

YES

25.00% Coinsurance after deductible

100.00%
Routine Foot Care
YES

25.00% Coinsurance after deductible

100.00%
Sexual Dysfunction

Sexual Dysfunction For Treatment of Organic Disease

YES

25.00% Coinsurance after deductible

100.00%
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

Exclusions: Covered health services do not include custodial, domiciliary care, or long-term care admissions.

YES

25.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$60.00

100.00%
Specialty Drugs

Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document.

Certain off-label uses of cancer drugs will be covered in accordance with state law.

YES

$250.00

100.00%
Sterilization
YES

25.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Exclusions: Excludes, "Inpatient confinements that are primarily intended as a change of environment"; Counseling with relatives of a patient.

YES

25.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Exclusions: Excludes counseling with relatives about a patient.

Includes biofeedback.

YES

$30.00

100.00%
Transplant

Exclusions: The purchase price of organs or tissue if any organ or tissue is sold rather than donated to the recipient member; the procurement of organs, tissue, bone marrow, or peripheral blood stem cells or any other donor services if a recipient is not a member; transplants, including high dose chemotherapy, considered experimental or investigational; services for or related to the transplantation of animal or artificial organs or tissues.

Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient's coverage. Reasonable costs for travel and lodging are covered and will be reimbursed for a covered transplant based on AmeriHealth guidelines available from our transplant coordinator.

YES

25.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Exclusions: Coverage is not provided for orthodontic braces, crowns, bridges, dentures, treatment for periodontal disease, dental root form implants, or root canals.

Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. If TMJ is caused by malocclusion, benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY.

YES

25.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$45.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging

Exclusions: Lab tests that are not ordered by a Doctor or Other Provider.

YES

25.00% Coinsurance after deductible

100.00%

AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards Health Insurance Plan Variant 17414NC0010009-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.780017779
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 1
Disease Management Programs Offered Asthma, Diabetes, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID NCF004
Formulary URL URL
HIOS Product ID 17414NC001
Import Date 3/1/2023 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 17414
Issuer Marketplace Marketing Name AmeriHealth Caritas Next
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 NCN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 17414NC0010009-00
Plan Marketing Name AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards
Plan Type HMO
Plan Variant Marketing Name AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,600
SBC Scenario, Having a Baby, Copayment $70
SBC Scenario, Having a Baby, Deductible $2,000
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $900
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $20
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 NCS001
Source Name HIOS
Plan ID 17414NC0010009
State Code NC
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 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 $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 AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards Health Insurance Plan, 17414NC0010009

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

Frequently Asked Questions(FAQ) about AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards, 17414NC0010009 Health Insurance Plan, 17414NC0010009

  • Does AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards Health Insurance Plan, 17414NC0010009 support Mail Ordering?

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

  • Does (17414NC0010009) Health Insurance Plan, Variant (17414NC0010009-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Diabetes, Pregnancy, Weight Loss Programs

    Does (17414NC0010009) Health Insurance Plan, Variant (17414NC0010009-00) have Out Of Country Coverage?

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

    Does (17414NC0010009) Health Insurance Plan, Variant (17414NC0010009-00) have Out of Service Area Coverage?

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

    Does (17414NC0010009) Health Insurance Plan, Variant (17414NC0010009-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Diabetes, Pregnancy, Weight Loss Programs

    Does AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards Health Insurance Plan, Variant (17414NC0010009-00) offer Disease Management Programs for Asthma?

    Yes, the AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards Health Insurance Plan Variant 17414NC0010009-00 offers Disease Management Program for Asthma.

    Does AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards Health Insurance Plan, Variant (17414NC0010009-00) offer Disease Management Programs for Diabetes?

    Yes, the AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards Health Insurance Plan Variant 17414NC0010009-00 offers Disease Management Program for Diabetes.

    Does AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards Health Insurance Plan, Variant (17414NC0010009-00) offer Disease Management Programs for Pregnancy?

    Yes, the AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards Health Insurance Plan Variant 17414NC0010009-00 offers Disease Management Program for Pregnancy.

    Does AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards Health Insurance Plan, Variant (17414NC0010009-00) offer Disease Management Programs for Weight loss programs?

    Yes, the AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards Health Insurance Plan Variant 17414NC0010009-00 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