Anthem HealthKeepers Catastrophic X 9100 - 88380VA0720015 Health Insurance Plan

HealthKeepers, Inc. health insurance plan with the Plan ID 88380VA0720015. The plan is called Anthem HealthKeepers Catastrophic X 9100 .

Health Insurance Plan ID 88380VA0720015
Health Insurance Plan Year 2023
State Virginia
Health Insurance Issuer HealthKeepers, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 88380VA0720015-00
Provider Network(s) ['VAN001']
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 Virginia 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 - 88380VA0720015-00

Standard On Exchange Plan - 88380VA0720015-01

Last Plan Update Date Wed, 25 Jan 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Anthem HealthKeepers Catastrophic X 9100 Health Insurance Plan, 88380VA0720015-00

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

Treatment must begin within 12 months of the injury, or as soon after that as possible, to be covered. Cost-Share(s) determined based on type of service and place of service rendered.

YES

No Charge after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

No Charge after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

No Charge after deductible

100.00%
Chemotherapy
YES

No Charge after deductible

100.00%
Chiropractic Care

Limit: 30.0 Visit(s) per Benefit Period

Rehabilitative Chiropractic care / spinal manipulation is limited to 30 visits per benefit period. Habilitative Chiropractic care / spinal manipulation is limited to 30 visits per year. Habilitation service limits are not combined with Rehabilitative service limits.

YES

No Charge after deductible

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

This benefit is for the hospital stay.

YES

No Charge after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Year

Limited to 2 visits per year.

YES

No Charge after deductible

100.00%
Diabetes Education

Cost-Share(s) determined based on type of service and place of service rendered.

YES

No Charge after deductible

100.00%
Dialysis
YES

No Charge after deductible

100.00%
Durable Medical Equipment

Coverage for ongoing rental of equipment may be limited to the cost of purchasing the equipment.

YES

No Charge after deductible

100.00%
Emergency Room Services
YES

No Charge after deductible

No Charge after deductible
Emergency Transportation/Ambulance

Benefits for Non-Emergency ambulance services when services have been pre-authorized by Anthem will be limited to $50,000 per occurrence if a Non-Network Provider is used. Includes medically necessary transportation to the nearest appropriate hospital for a medical emergency, or between hospitals or other approved facilities. Includes ground, water, fixed wing and rotary air transportation. Benefits also include medically necessary treatment of a sickness or injury by medical professionals from an ambulance service, even if you are not taken to a facility. Benefits are only available for air ambulance when it is not appropriate to use a ground or water ambulance.

YES

No Charge after deductible

No Charge after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Includes a choice of eyeglasses lenses or contact lenses within a benefit period. Covered eyeglasses lenses include standard plastic lenses in: Single vision, Bifocal, Trifocal, and Standard Progressive. Members choose from a limited frame selection. Coverage for contact lenses includes elective or non-elective contact lenses. Non-elective contact lenses are covered only for certain medical conditions. Limited to 1 item per year.

YES

$0.00 Copay after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs

30 day supply retail. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.

YES

0.00% Coinsurance after deductible

100.00%
Habilitation Services

Habilitation Speech therapy limited to 30 visits per year. Habilitative Physical therapy and Occupational therapy have a combined limit of 30 visits per benefit period. Habilitative service limits are not combined with Rehabilitation service limits. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.

YES

No Charge after deductible

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 100.0 Visit(s) per Benefit Period

The Home Care visit limit will apply instead of the Therapy Services limits for physical, occupational, speech therapy, or cardiac rehabilitation for therapy in the home. Visit limit does not apply to home infusion therapy or home dialysis. Limited to 100 visits per benefit period.

YES

No Charge after deductible

100.00%
Hospice Services
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Inpatient Physician and Surgical Services
YES

No Charge after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

No Charge after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

No Charge after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

No Charge after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

No Charge after deductible

100.00%
Non-Preferred Brand Drugs

30 day supply retail. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.

YES

0.00% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

No Charge after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Orthodontic Fixed Appliance Therapy, which is treatment that uses an appliance that is cemented or bonded to the teeth, is covered only once per lifetime for Dentally Necessary Coverage only.

YES

No Charge after deductible

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

Primary Care Office Visit has 3 $40 copays only; visit 4+, no charge after deductible. Copay is for office visit only, other services provided during the visit are subject to additional cost shares. Copay limit is for Primary Care Office Visits, Other Practitioner Office Visits (Nurse, Physician Assistant), Doctor Visits in the Home, and Online Office Visits combined. Specialists Visits, Mental Health and Substance Use Office Visits apply deductible. Copays do not apply to these services. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our mobile application, website, or HealthKeepers enabled device.

YES

No Charge after deductible

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

No Charge after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Benefit Period

Rehabilitation Speech therapy limited to 30 visits per year. Rehabilitative Physical therapy and Occupational therapy have a combined limit of 30 visits per benefit period. Rehabilitative service limits are not combined with Habilitation service limits. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.

YES

No Charge after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge after deductible

100.00%
Preferred Brand Drugs

30 day supply retail. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.

YES

0.00% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care
YES

No Charge after deductible

100.00%
Preventive Care/Screening/Immunization

You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

Primary Care Office Visit has 3 $40 copays only; visit 4+, no charge after deductible. Copay is for office visit only, other services provided during the visit are subject to additional cost shares. Copay limit is for Primary Care Office Visits, Other Practitioner Office Visits (Nurse, Physician Assistant), Doctor Visits in the Home, and Online Office Visits combined. Specialists Visits, Mental Health and Substance Use Office Visits apply deductible. Copays do not apply to these services. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our mobile application, website, or HealthKeepers enabled device.

YES

No Charge after deductible

100%
Private-Duty Nursing

Limit: 16.0 Hours per Benefit Period

Private-Duty nursing in a home setting only. Limited to 16 hours per benefit period.

YES

No Charge after deductible

100.00%
Prosthetic Devices

The coinsurance for prosthetics for limb replacement can be no greater than 30%. Per the mandate "Limb" means an arm, a hand, a leg, a foot, or any portion of an arm, a hand, a leg, or a foot. All other prosthetic services are covered under the plan's base coinsurance (Coinsurance formula: If plan coinsurance is greater than 30% then coinsurance for Prosthetics for Limb Replacement is 30%. If plan coinsurance is equal to a less than 30% then consurance for Prosthetics for Limb Replacement, should be the plan coinsurance).

YES

No Charge after deductible

100.00%
Radiation
YES

No Charge after deductible

100.00%
Reconstructive Surgery
YES

No Charge after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Benefit Period

Rehabilitation Physical therapy and Occupational therapy limited to 30 visits per benefit period combined. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. Rehabilitative service limits are not combined with Habilitation service limits.

YES

No Charge after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Benefit Period

Rehabilitation Speech therapy limited to 30 visits per benefit period. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. Rehabilitative service limits are not combined with Habilitation service limits.

YES

No Charge after deductible

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

Limit: 1.0 Visit(s) per Benefit Period

Includes complete eye exam with dilation, as needed to check all aspects of vision, including the structure of the eyes. Limited to 1 visit per year.

YES

$0.00 Copay after deductible

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 100.0 Days per Stay

Limited to 100 days per stay.

YES

No Charge after deductible

100.00%
Specialist Visit

Specialists Visits, Mental Health and Substance Use Office Visits apply deductible/coinsurance. Copays do not apply to these services. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our mobile application, website, or HealthKeepers enabled device.

YES

No Charge after deductible

100.00%
Specialty Drugs

30 day supply retail. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.

YES

0.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

No Charge after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

No Charge after deductible

100.00%
Transplant

Unrelated Donor Search limited to a maximum of the 10 best matched donors, identified by an authorized registry. Medically Necessary charges for the procurement of an organ from a live donor are covered up to the maximum allowed amount, including complications from the donor procedure for up to six weeks from the date of procurement.

YES

No Charge after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

No Charge after deductible

100.00%
Urgent Care Centers or Facilities
YES

No Charge after deductible

No Charge after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

No Charge after deductible

100.00%

Anthem HealthKeepers Catastrophic 9100 Health Insurance Plan Variant 88380VA0720015-00 Attributes

Plan Attribute Value
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 3
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Catastrophic Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID VAF004
Formulary URL URL
HIOS Product ID 88380VA072
Import Date 1/25/2023 20:01
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 88380
Issuer Marketplace Marketing Name HealthKeepers, Inc.
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Catastrophic
Multiple In Network Tiers No
National Network No
Network ID VAN001
Out of Country Coverage No
Out of Country Coverage Description Urgent/Emergency Coverage Only
Out of Service Area Coverage No
Out of Service Area Coverage Description TRAD/PAR network
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 88380VA0720015-00
Plan Marketing Name Anthem HealthKeepers Catastrophic X 9100
Plan Type HMO
Plan Variant Marketing Name Anthem HealthKeepers Catastrophic 9100
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $9,100
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $100
SBC Scenario, Having Diabetes, Deductible $5,200
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID VAS003
Source Name SERFF
Plan ID 88380VA0720015
State Code VA
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 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $18200 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $9100 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $9,100
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 $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,100
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 Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Anthem HealthKeepers Catastrophic X 9100 Health Insurance Plan, 88380VA0720015

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

Frequently Asked Questions(FAQ) about Anthem HealthKeepers Catastrophic X 9100 , 88380VA0720015 Health Insurance Plan, 88380VA0720015

  • Does Anthem HealthKeepers Catastrophic X 9100 Health Insurance Plan, 88380VA0720015 support Mail Ordering?

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

  • Does (88380VA0720015) Health Insurance Plan, Variant (88380VA0720015-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management

    Does (88380VA0720015) Health Insurance Plan, Variant (88380VA0720015-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan). Details: Urgent/Emergency Coverage Only

    Does (88380VA0720015) Health Insurance Plan, Variant (88380VA0720015-00) 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: TRAD/PAR network

    Does (88380VA0720015) Health Insurance Plan, Variant (88380VA0720015-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management

    Does Anthem HealthKeepers Catastrophic 9100 Health Insurance Plan, Variant (88380VA0720015-00) offer Disease Management Programs for Asthma?

    Yes, the Anthem HealthKeepers Catastrophic 9100 Health Insurance Plan Variant 88380VA0720015-00 offers Disease Management Program for Asthma.

    Does Anthem HealthKeepers Catastrophic 9100 Health Insurance Plan, Variant (88380VA0720015-00) offer Disease Management Programs for Heart disease?

    Yes, the Anthem HealthKeepers Catastrophic 9100 Health Insurance Plan Variant 88380VA0720015-00 offers Disease Management Program for Heart disease.

    Does Anthem HealthKeepers Catastrophic 9100 Health Insurance Plan, Variant (88380VA0720015-00) offer Disease Management Programs for Depression?

    Yes, the Anthem HealthKeepers Catastrophic 9100 Health Insurance Plan Variant 88380VA0720015-00 offers Disease Management Program for Depression.

    Does Anthem HealthKeepers Catastrophic 9100 Health Insurance Plan, Variant (88380VA0720015-00) offer Disease Management Programs for Diabetes?

    Yes, the Anthem HealthKeepers Catastrophic 9100 Health Insurance Plan Variant 88380VA0720015-00 offers Disease Management Program for Diabetes.

    Does Anthem HealthKeepers Catastrophic 9100 Health Insurance Plan, Variant (88380VA0720015-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Anthem HealthKeepers Catastrophic 9100 Health Insurance Plan Variant 88380VA0720015-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Anthem HealthKeepers Catastrophic 9100 Health Insurance Plan, Variant (88380VA0720015-00) offer Disease Management Programs for Low back pain?

    Yes, the Anthem HealthKeepers Catastrophic 9100 Health Insurance Plan Variant 88380VA0720015-00 offers Disease Management Program for Low back pain.

 

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