CareSource Marketplace Standard Silver - 60224GA0020004 Health Insurance Plan

CareSource Georgia Co. health insurance plan with the Plan ID 60224GA0020004. The plan is called CareSource Marketplace Standard Silver.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.14% (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 29.86% 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 60224GA0020004
Health Insurance Plan Year 2023
State Georgia
Health Insurance Issuer CareSource Georgia Co.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 60224GA0020004-00
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 - 60224GA0020004-00

Standard On Exchange Plan - 60224GA0020004-01

Open to Indians below 300% FPL - 60224GA0020004-02

Open to Indians above 300% FPL - 60224GA0020004-03

73% AV Silver Plan - 60224GA0020004-04

87% AV Silver Plan - 60224GA0020004-05

94% AV Silver Plan - 60224GA0020004-06

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

Benefits of CareSource Marketplace Standard Silver Health Insurance Plan, 60224GA0020004-00

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

Injury as a result of chewing or biting is not considered an accidental injury.

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

$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits.

YES

25.00%

100.00%
Basic Dental Care - Child

See plan documents for details on benefit limits

YES

25.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

40.00% Coinsurance after deductible

100.00%
Chiropractic Care
NO
Cosmetic Surgery

Cosmetic Procedures do not include coverage for procedures or services that change or improve appearance without significantly improving physiological function, other than those mandated by State or Federal law.

YES

40.00% Coinsurance after deductible

100.00%
Delivery and All Inpatient Services for Maternity Care
YES

$500.00 Copay after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Procedure(s) per Year

See plan documents for details on benefit limits

YES

$0.00

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

Emergency room copay or coinsurance is waived if you are admitted to the hospital directly from the Emergency Department.

YES

$500.00 Copay after deductible

$500.00 Copay after deductible
Emergency Transportation/Ambulance

Ambulance transports must be made to the closest local facility that can provide you with covered services appropriate for your medical condition.

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Limited to one pair of glasses or contact lenses per benefit year.

YES

$0.00, 0.00%

100.00%
Gender Affirming Care
YES

40.00% Coinsurance after deductible

100.00%
Generic Drugs
YES

$20.00

100.00%
Habilitation Services

Limit: 40.0 Visit(s) per Year

Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, and Spinal Manipulations are limited to a combined 40 visits per Benefit Year

YES

$30.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 120.0 Visit(s) per Year

A visit equals at least 2 hours

YES

40.00% Coinsurance after deductible

100.00%
Hospice Services
YES

40.00% Coinsurance after deductible

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

$250.00 Copay 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

$500.00 Copay per Stay after deductible

100.00%
Inpatient Physician and Surgical Services
YES

0.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

$50.00

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

$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits.

YES

45.00%

100.00%
Major Dental Care - Child

See plan documents for details on benefit limits

YES

45.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

$500.00 Copay per Stay after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$30.00

100.00%
Non-Preferred Brand Drugs
YES

40.00% Coinsurance after deductible

100.00%
Nutritional Counseling

Limit: 4.0 Visit(s) per Year

YES

40.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Limited to Medically Necessary Orthodontia. See plan documents for details on benefit limits.

YES

55.00% 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

40.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 40.0 Visit(s) per Year

Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Manipulation Therapy, and Cognitive Rehabilitation therapy are limited to a combined 40 visits per year

YES

40.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$70.00

100.00%
Prenatal and Postnatal Care
YES

$70.00

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

0.00%

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

$30.00

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

Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy.

YES

40.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Year

Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Manipulation Therapy, and Cognitive Rehabilitation therapy are limited to a combined 40 visits per year

YES

$30.00

100.00%
Rehabilitative Speech Therapy

Limit: 40.0 Visit(s) per Year

Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Manipulation Therapy, and Cognitive Rehabilitation therapy are limited to a combined 40 visits per year

YES

40.00% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)

Limit: 2.0 Visit(s) per Year

$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits.

YES

$0.00

100.00%
Routine Eye Exam (Adult)

Limit: 1.0 Exam(s) per Year

YES

$50.00

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

$0.00, 0.00%

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

$500.00 Copay per Stay after deductible

100.00%
Specialist Visit
YES

$70.00

100.00%
Specialty Drugs
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

$500.00 Copay per Stay after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$30.00

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

$60.00

$60.00
Weight Loss Programs

Limit: 4.0 Visit(s) per Year

Nutritional counseling for the treatment of obesity, which includes morbid obesity.

YES

40.00% Coinsurance after deductible

100.00%
Well Baby Visits and Care

Care provided for birth through age 5.

YES

0.00%

100.00%
X-rays and Diagnostic Imaging
YES

$200.00 Copay after deductible

100.00%

CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan Variant 60224GA0020004-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.701403743
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 Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 0.98000784
First Tier Utilization 100%
Formulary ID GAF008
Formulary URL URL
HIOS Product ID 60224GA002
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 Existing
Notice Required for Pregnancy Yes
Is a Referral Required for Specialist? No
Issuer ID 60224
Issuer Marketplace Marketing Name CareSource
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 Yes
Out of Country Coverage Description Emergency Services Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Services Only
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 60224GA0020004-00
Plan Marketing Name CareSource Marketplace Standard Silver
Plan Type HMO
Plan Variant Marketing Name CareSource Marketplace Standard Silver Dental, Vision &, Fitness
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $1,000
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 $600
SBC Scenario, Having Diabetes, Deductible $3,900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,100
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID GAS001
Source Name HIOS
Plan ID 60224GA0020004
State Code GA
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $17800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $8900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $8,900
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $11600 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $5800 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $5,800
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 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 $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 Yes

Copay & Coinsurance of CareSource Marketplace Standard Silver Health Insurance Plan, 60224GA0020004

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

Frequently Asked Questions(FAQ) about CareSource Marketplace Standard Silver, 60224GA0020004 Health Insurance Plan, 60224GA0020004

  • Does CareSource Marketplace Standard Silver Health Insurance Plan, 60224GA0020004 support Mail Ordering?

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

  • Does (60224GA0020004) Health Insurance Plan, Variant (60224GA0020004-00) 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, Pregnancy, Weight Loss Programs

    Does (60224GA0020004) Health Insurance Plan, Variant (60224GA0020004-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (60224GA0020004) Health Insurance Plan, Variant (60224GA0020004-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services Only

    Does (60224GA0020004) Health Insurance Plan, Variant (60224GA0020004-00) 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, Pregnancy, Weight Loss Programs

    Does CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan, Variant (60224GA0020004-00) offer Disease Management Programs for Asthma?

    Yes, the CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan Variant 60224GA0020004-00 offers Disease Management Program for Asthma.

    Does CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan, Variant (60224GA0020004-00) offer Disease Management Programs for Heart disease?

    Yes, the CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan Variant 60224GA0020004-00 offers Disease Management Program for Heart disease.

    Does CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan, Variant (60224GA0020004-00) offer Disease Management Programs for Depression?

    Yes, the CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan Variant 60224GA0020004-00 offers Disease Management Program for Depression.

    Does CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan, Variant (60224GA0020004-00) offer Disease Management Programs for Diabetes?

    Yes, the CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan Variant 60224GA0020004-00 offers Disease Management Program for Diabetes.

    Does CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan, Variant (60224GA0020004-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan Variant 60224GA0020004-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan, Variant (60224GA0020004-00) offer Disease Management Programs for Low back pain?

    Yes, the CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan Variant 60224GA0020004-00 offers Disease Management Program for Low back pain.

    Does CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan, Variant (60224GA0020004-00) offer Disease Management Programs for Pregnancy?

    Yes, the CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan Variant 60224GA0020004-00 offers Disease Management Program for Pregnancy.

    Does CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan, Variant (60224GA0020004-00) offer Disease Management Programs for Weight loss programs?

    Yes, the CareSource Marketplace Standard Silver Dental, Vision &, Fitness Health Insurance Plan Variant 60224GA0020004-00 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