Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) - 27248TX0010013 Health Insurance Plan

Community Health Choice, Inc. health insurance plan with the Plan ID 27248TX0010013. The plan is called Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.10% (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 29.90% 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 27248TX0010013
Health Insurance Plan Year 2023
State Texas
Health Insurance Issuer Community Health Choice, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 27248TX0010013-00
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 - 27248TX0010013-00

Standard On Exchange Plan - 27248TX0010013-01

Open to Indians below 300% FPL - 27248TX0010013-02

Open to Indians above 300% FPL - 27248TX0010013-03

73% AV Silver Plan - 27248TX0010013-04

87% AV Silver Plan - 27248TX0010013-05

94% AV Silver Plan - 27248TX0010013-06

Last Plan Update Date Thu, 23 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) Health Insurance Plan, 27248TX0010013-00

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

Cost sharing and limitation depend on type and site of service. Limited to treatment for a Dental Injury to a Sound Natural Tooth.

YES

0.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing

Cost sharing depends on type and site of service

YES

0.00% Coinsurance after deductible

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

Cost sharing and limitation depend on type and site of service. Injectable chemotherapeutic agents require preauthorization.

YES

0.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 35.0 Visit(s) per Year

Limited to combined 35 visits per year.

YES

0.00% Coinsurance after deductible

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

Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section. Prior authorization required for maternity and newborn stays that exceed 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.

YES

0.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Cost sharing depends on type and site of service.

YES

0.00% Coinsurance after deductible

100.00%
Dialysis

Cost sharing depends on type and site of service.

YES

0.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Certain services require preauthorization (DME over $500).

YES

0.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Exclusions: Travel or ambulance services for convenience.

Prior authorization required for out of network ambulance services, out of area transfers, non-emergency ground transportation, air transportation, and facility to facility transfers. Prior authorization is not necessary when the service is medically necessary and any other form of transportation would put the Member?s health or safety at risk. As of January 1, 2022, the No Surprises Act prohibits surprise billing for Consumers with Out-of-Network emergency services, including air ambulance (but not ground ambulance) services.

YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

For select frames, standard lenses, and contact lenses only.

YES

0.00% Coinsurance after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs

Subject to formulary requirements and preauthorization may be required (when generic is not the preferred agent).

YES

$10.00

100.00%
Habilitation Services

Cost sharing depends on type and site of service. Limited to medical necessity. Prior authorization is required.

YES

0.00% Coinsurance after deductible

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

To restore or correction of impaired speech or hearing loss. Each ear, every three years. Prior authorization is required.

YES

0.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

Prior Authorization is required.

YES

0.00% Coinsurance after deductible

100.00%
Hospice Services

Cost sharing and limitations depend on type and site of service.

YES

0.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)

Preauthorization is required.

YES

0.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy

Cost sharing and limitation depend on type and site of service. Preauthorization is required.

YES

0.00% Coinsurance after deductible

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

Prior Authorization is required.

YES

0.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services

Prior Authorization is required for inpatient surgical services.

YES

0.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services

Some services require preauthorization.

YES

0.00% 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

Preauthorization is required.

YES

0.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Certain services require preauthorization.Cost sharing depends on type and site of service. This benefit (Mental/Behavioral Health Outpatient Services, Substance Abuse Disorder Outpatient Services, and Habilitation Services) is subject to different cost-sharing depending on whether the service is an office visit or other outpatient service. Office visits are subject to copays, while facility-based services are subject to coinsurance.

YES

$10.00

100.00%
Non-Preferred Brand Drugs

Subject to formulary requirements and preauthorization may be required.

YES

0.00% Coinsurance after deductible

100.00%
Nutritional Counseling

Preauthorization is required. Cost sharing depends on type and site of service.

YES

0.00% Coinsurance after deductible

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

Cost sharing and limitations depend on type and site of service.

YES

$10.00

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

Cost sharing and limitations depend on the type and site of service. Preauthorization is required for outpatient surgeries.

YES

0.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limited to Medically Necessary outpatient Rehabilitative Therapy visits to or by a Participating Provider other than a Primary Care Physician. Prior authorization is required.

YES

0.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services

Outpatient services and Habilitation Services are subject to different cost-sharing depending on whether the service is an office visit or other outpatient service. Office visits are subjec to copays, while facility-based services are subject to coinsurance. Preauthorization is required for outpatient surgeries.

YES

0.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Subject to formulary requirements and preauthorization may be required.

YES

0.00% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care
YES

0.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

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

$10.00

100.00%
Private-Duty Nursing

Inpatient private duty nursing.

YES

0.00% Coinsurance after deductible

100.00%
Prosthetic Devices

Preauthorization is required.

YES

0.00% Coinsurance after deductible

100.00%
Radiation

Cost sharing and limitation depend on type and site of service. Proton beam radiation requires preauthorization.

YES

0.00% 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. Preauthorization is required. Cost sharing depends on type and site of service.

YES

0.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Prior Authorization is required. Limited to medical necessity.

YES

0.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Prior Authorization is required. Limited to medical necessity.

YES

0.00% Coinsurance 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 Year

Covered services for children 18 and under.

YES

0.00% Coinsurance after deductible

100.00%
Routine Foot Care

Coverage for foot care is limited to members with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency is covered. Any services or supplies in connection with routine foot care, including the removal of warts, corns, or calluses, or the cutting and trimming of toenails in the absence of diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency are excluded. Cost sharing and limitations depend on site of service.

YES

0.00% Coinsurance after deductible

100.00%
Skilled Nursing Facility

Limit: 25.0 Days per Year

Cost sharing and limitation depend on type and site of service. Prior authorization is required.

YES

0.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$20.00

100.00%
Specialty Drugs

Subject to formulary requirements and preauthorization may be required.

YES

0.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Preauthorization is required.

YES

0.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Certain services require preauthorization. Cost sharing depends on type and site of service. This benefit (Mental/Behavioral Health Outpatient Services, Substance Abuse Disorder Outpatient Services, and Habilitation Services) is subject to different cost-sharing depending on whether the service is an office visit or other outpatient service. Office visits are subject to copays, while facility-based services are subject to coinsurance.

YES

$10.00

100.00%
Transplant

Exclusions: Subject to the conditions described below, benefits for covered services and supplies provided to a Participant by a Hospital, Physician, or Other Provider related to an organ or tissue transplant will be determined as follows, but only if all the following conditions are met: (1) The transplant procedure is not Experimental/Investigational in nature; and (2) Donated human organs or tissue or an FDA-approved artificial device are used; and (3) The recipient is a Participant under the Plan; and (4) The transplant procedure is preauthorized as required under the Plan; and (5) The Participant meets all of the criteria established by CHC in pertinent written medical policies; and (6) The Participant meets all of the protocols established by the Hospital in which the transplant is performed. Donor expenses for a Participant in connection with an organ or tissue transplant is not a covered benefit if the recipient is not covered under this Plan. No benefits are available for any organ or tissue transplant procedure (or services performed in preparation for, or in conjunction with, such procedure) which CHC considers to be Experimental/Investigational.

Preauthorization is required. Cost sharing and limitation depend on type and site of service.

YES

0.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Prior authorization required for temporomandibular joint surgery.

YES

0.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$20.00

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

No Charge

100.00%
X-rays and Diagnostic Imaging

Prior Authorization is required.

YES

0.00% Coinsurance after deductible

100.00%

Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) Health Insurance Plan Variant 27248TX0010013-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.700970931
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, Diabetes, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID TXF006
Formulary URL URL
HIOS Product ID 27248TX001
Import Date 2/23/2023 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 27248
Issuer Marketplace Marketing Name Community Health Choice
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 TXN001
Out of Country Coverage No
Out of Service Area Coverage No
Out of Service Area Coverage Description For emergency only
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 27248TX0010013-00
Plan Marketing Name Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth)
Plan Type HMO
Plan Variant Marketing Name Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $8,500
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $300
SBC Scenario, Having Diabetes, Deductible $4,100
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $70
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID TXS001
Source Name HIOS
Plan ID 27248TX0010013
State Code TX
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $17000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $8500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $8,500
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $17000 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $8500 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $8,500
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 $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 $17000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,500
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 Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) Health Insurance Plan, 27248TX0010013

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

Frequently Asked Questions(FAQ) about Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth), 27248TX0010013 Health Insurance Plan, 27248TX0010013

  • Does Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) Health Insurance Plan, 27248TX0010013 support Mail Ordering?

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

  • Does (27248TX0010013) Health Insurance Plan, Variant (27248TX0010013-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does (27248TX0010013) Health Insurance Plan, Variant (27248TX0010013-00) have Out Of Country Coverage?

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

    Does (27248TX0010013) Health Insurance Plan, Variant (27248TX0010013-00) 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: For emergency only

    Does (27248TX0010013) Health Insurance Plan, Variant (27248TX0010013-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) Health Insurance Plan, Variant (27248TX0010013-00) offer Disease Management Programs for Asthma?

    Yes, the Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) Health Insurance Plan Variant 27248TX0010013-00 offers Disease Management Program for Asthma.

    Does Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) Health Insurance Plan, Variant (27248TX0010013-00) offer Disease Management Programs for Heart disease?

    Yes, the Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) Health Insurance Plan Variant 27248TX0010013-00 offers Disease Management Program for Heart disease.

    Does Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) Health Insurance Plan, Variant (27248TX0010013-00) offer Disease Management Programs for Diabetes?

    Yes, the Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) Health Insurance Plan Variant 27248TX0010013-00 offers Disease Management Program for Diabetes.

    Does Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) Health Insurance Plan, Variant (27248TX0010013-00) offer Disease Management Programs for Pregnancy?

    Yes, the Community Premier Silver 013 (No deductible for PCP, Specialists, Urgent Care & Generics, Free 24/7 Telehealth) Health Insurance Plan Variant 27248TX0010013-00 offers Disease Management Program for Pregnancy.

 

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