CHRISTUS Standard Gold - 66252TX0290013 Health Insurance Plan

CHRISTUS Health Plan health insurance plan with the Plan ID 66252TX0290013. The plan is called CHRISTUS Standard Gold.

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 66252TX0290013
Health Insurance Plan Year 2023
State Texas
Health Insurance Issuer CHRISTUS Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 66252TX0290013-00
Provider Network(s) ['TXN001']
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 Texas 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 - 66252TX0290013-00

Standard On Exchange Plan - 66252TX0290013-01

Open to Indians below 300% FPL - 66252TX0290013-02

Open to Indians above 300% FPL - 66252TX0290013-03

Last Plan Update Date Fri, 24 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of CHRISTUS Standard Gold Health Insurance Plan, 66252TX0290013-00

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

25% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

$60.00

100.00%
Autism Spectrum Disorders

Texas State Required Benefit

YES

$30.00

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Brain Injury

Texas State Required Benefit

YES

25% Coinsurance after deductible

100.00%
Chemotherapy
YES

25% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 35.0 Visit(s) per Year

Limited to combined 35 visits per year, including Outpatient Rehabilitation Services. Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

$30.00

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

Preauthorization is required for inpatient care, except for: (1) forty-eight (48) hours of Inpatient care following an uncomplicated vaginal delivery or ninety-six (96) hours of Inpatient care following an uncomplicated Cesarean section or (2) Post-Partum Care. If you don?t get preauthorization, benefits will be denied.

YES

25% Coinsurance after deductible

100.00%
Dental Check-Up for Children
YES

No Charge

100.00%
Diabetes Care Management

Texas State Required Benefit

YES

$30.00

100.00%
Diabetes Education
YES

No Charge

100.00%
Dialysis
YES

25% Coinsurance after deductible

100.00%
Durable Medical Equipment

Preauthorization is required for some durable medical equipment. If you don't get preauthorization, benefits will be denied.

YES

25% Coinsurance after deductible

100.00%
Emergency Room Services
YES

25% Coinsurance after deductible

25% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

25% Coinsurance after deductible

25% Coinsurance after deductible
Eye Glasses for Adults
NO
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

No Charge

100.00%
Fitness Benefit - Adult
NO
Gender Affirming Care
NO
Generic Drugs

Cost sharing for a 90-day supply by mail order is triple the cost sharing for a standard 30-day supply. Prescriptions for birth control are not subject to deductible, and do not have a copayment.

YES

$15.00

100.00%
Habilitation Services

Habilitative and rehabilitative limits cannot be combined for plans issued or renewed on or after January 1, 2017. Habilitation services includes autism services, and the benchmark plan does not impose age or maximums on autism coverage. MH/SUD office visits are subject to the listed cost sharing, while MH/SUD facility outpatient treatments are subject to the outpatient facility coinsurance. Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

$30.00

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

To restore or correction of impaired speech or hearing loss. 1 hearing aid in each ear every 3 years limited to $2,000 benefit maximum per device

YES

25% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

25% Coinsurance after deductible

100.00%
Hospice Services

Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

25% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)

Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

25% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

$60.00

100.00%
Inherited Metabolic Disorder - PKU

Texas State Required Benefit

YES

25% Coinsurance after deductible

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

All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units. Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

25% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services

Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

25% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

25% 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

Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

25% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

MH/SUD office visits are subject to the listed cost sharing, while MH/SUD facility outpatient treatments are subject to the outpatient facility coinsurance.

YES

$30.00

100.00%
Mental Health Other
NO
Newborn Hearing Screening
NO
Non-Preferred Brand Drugs

Cost sharing for a 90-day supply by mail order is triple the cost sharing for a standard 30-day supply. Prescriptions for birth control are not subject to deductible, and do not have a copayment.

YES

$60.00

100.00%
Nutritional Counseling
NO
Off Label Prescription Drugs

Texas State Required Benefit

YES

$250.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$60.00

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

Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

25% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 35.0 Visit(s) per Year

Limited to combined 35 visits per year, including Chiropractic. Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

$30.00

100.00%
Outpatient Surgery Physician/Surgical Services

Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

25% Coinsurance after deductible

100.00%
Pediatric Services Other

Texas State Required Benefit

YES

25% Coinsurance after deductible

100.00%
Post-Mastectomy Care

Texas State Required Benefit

YES

$60.00

100.00%
Preferred Brand Drugs

Cost sharing for a 90-day supply by mail order is triple the cost sharing for a standard 30-day supply. Prescriptions for birth control are not subject to deductible, and do not have a copayment.

YES

$30.00

100.00%
Prenatal and Postnatal Care
YES

$60.00

100.00%
Prescription Drugs Other

Texas State Required Benefit

YES

$250.00

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

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

$30.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices

Medically necessary foot orthotics are not subject to a calendar year maximum.

YES

25% Coinsurance after deductible

100.00%
Radiation
YES

25% Coinsurance after deductible

100.00%
Reconstructive Surgery

Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed.

YES

25% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

$30.00

100.00%
Rehabilitative Speech Therapy

Preauthorization is required. If you don't get preauthorization, benefits will be denied.

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 Year

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 25.0 Days per Year

Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

25% Coinsurance after deductible

100.00%
Specialist Visit
YES

$60.00

100.00%
Specialty Drugs
YES

$250.00

100.00%
Substance Abuse Disorder Inpatient Services

Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

25% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

MH/SUD office visits are subject to the listed cost sharing, while MH/SUD facility outpatient treatments are subject to the outpatient facility coinsurance.

YES

$30.00

100.00%
Transplant

Preauthorization is required. If you don't get preauthorization, benefits will be denied.

YES

25% Coinsurance after deductible

100.00%
Transplant Donor Coverage

Texas State Required Benefit

YES

25% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Though state law only mandates coverage for temporomandibular joint (TMJ) disorders for large group plans and HMOs, the benchmark plan covers TMJ. Therefore, it is considered part of the EHB package for Texas.

YES

25% 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
YES

25% Coinsurance after deductible

100.00%

CHRISTUS Standard Gold Health Insurance Plan Variant 66252TX0290013-00 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 Diabetes
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID TXF009
Formulary URL URL
HIOS Product ID 66252TX029
Import Date 2/24/2023 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 66252
Issuer Marketplace Marketing Name CHRISTUS Health Plan
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 TXN001
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Services
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) 66252TX0290013-00
Plan Marketing Name CHRISTUS Standard Gold
Plan Type HMO
Plan Variant Marketing Name CHRISTUS Standard Gold
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,600
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $2,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $900
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
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 TXS013
Source Name HIOS
Plan ID 66252TX0290013
State Code TX
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $8,700
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $4000 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $2000 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $2,000
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 $4000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $2000 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $2,000
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 $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $8,700
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of CHRISTUS Standard Gold Health Insurance Plan, 66252TX0290013

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

Frequently Asked Questions(FAQ) about CHRISTUS Standard Gold, 66252TX0290013 Health Insurance Plan, 66252TX0290013

  • Does CHRISTUS Standard Gold Health Insurance Plan, 66252TX0290013 support Mail Ordering?

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

  • Does (66252TX0290013) Health Insurance Plan, Variant (66252TX0290013-00) offer Disease Management Programs?

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

    Does (66252TX0290013) Health Insurance Plan, Variant (66252TX0290013-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services

    Does (66252TX0290013) Health Insurance Plan, Variant (66252TX0290013-00) 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 (66252TX0290013) Health Insurance Plan, Variant (66252TX0290013-00) offer Disease Management Programs?

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

    Does CHRISTUS Standard Gold Health Insurance Plan, Variant (66252TX0290013-00) offer Disease Management Programs for Diabetes?

    Yes, the CHRISTUS Standard Gold Health Insurance Plan Variant 66252TX0290013-00 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