CommunityCare Gold IH222 - 98905OK0130044 Health Insurance Plan

CommunityCare HMO Inc. health insurance plan with the Plan ID 98905OK0130044. The plan is called CommunityCare Gold IH222.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.40% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.60% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.27% (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 21.73% 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 98905OK0130044
Health Insurance Plan Year 2023
State Oklahoma
Health Insurance Issuer CommunityCare HMO Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 98905OK0130044-00
Provider Network(s) ['OKN001']
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 Oklahoma 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 - 98905OK0130044-00

Standard On Exchange Plan - 98905OK0130044-01

Open to Indians below 300% FPL - 98905OK0130044-02

Open to Indians above 300% FPL - 98905OK0130044-03

Last Plan Update Date Tue, 28 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of CommunityCare Gold IH222 Health Insurance Plan, 98905OK0130044-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited

Exclusions: Abortions are excluded, except as allowed by law to protect the life of the mother from imminent danger

NO
Accidental Dental
YES

30.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

30.00% Coinsurance after deductible

100.00%
Bariatric Surgery

Exclusions: Except when medically necessary

NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

30.00% Coinsurance after deductible

100.00%
Chiropractic Care
YES

$55.00

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

30.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

No Charge

100.00%
Dialysis
YES

30.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

30.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

$300.00, 30.00% Coinsurance after deductible

$300.00, 30.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

$50.00 Copay after deductible

$50.00 Copay after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

1 pair of standard lenses and frames or contacts per year

YES

30.00% Coinsurance after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

$15.00

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Year

Up to 60 treatment days per disability, per calendar year. Combination of Physical Therapy, Occupational Therapy and Speech Therapy. Up to 390 visits per calendar year combined Physical Therapy, Occupational Therapy and Speech Therapy for members with Autism.

YES

30.00% Coinsurance after deductible

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 2 Years

1 hearing aid per ear every 48 months

YES

30.00% Coinsurance after deductible

100.00%
Home Health Care Services

Must be medically necessary and is subject to prior authorization

YES

30.00% Coinsurance after deductible

100.00%
Hospice Services
YES

No Charge

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

30.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy

Must be medically necessary and is subject to prior authorization

YES

30.00% Coinsurance after deductible

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

30.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

30.00%

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

30.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

30.00% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs
YES

$95.00 Copay after deductible

100.00%
Nutritional Counseling
YES

30.00% Coinsurance after deductible

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

$30.00

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

30.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Year

Up to 60 treatment days per disability, per calendar year. Combination of Physical Therapy, Occupational Therapy and Speech Therapy. Up to 390 visits per calendar year combined Physical Therapy, Occupational Therapy and Speech Therapy for members with Autism.

YES

30.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$45.00

100.00%
Prenatal and Postnatal Care
YES

No Charge

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

Limit: 85.0 Visit(s) per Year

YES

30.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

30.00% Coinsurance after deductible

100.00%
Radiation

Must be medically necessary and is subject to prior authorization

YES

30.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Exclusions: Surgery performed primarily to improve or alter the Member's external appearance is excluded

Covered in cases of mastectomies and medically necessary situations, and for medically necessary reconstructive surgery due to accidental injury, functional congenital defects, or deformities that are the result of treatment or illness that substantially impair bodily function.

YES

30.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 60.0 Visit(s) per Year

Up to 60 treatment days per disability, per calendar year. Combination of Physical Therapy, Occupational Therapy and Speech Therapy. Up to 390 visits per calendar year combined Physical Therapy, Occupational Therapy and Speech Therapy for members with Autism.

YES

30.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 60.0 Visit(s) per Year

Up to 60 treatment days per disability, per calendar year. Combination of Physical Therapy, Occupational Therapy and Speech Therapy. Up to 390 visits per calendar year combined Physical Therapy, Occupational Therapy and Speech Therapy for members with Autism.

YES

30.00% 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

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Visit(s) per Year

Up to 60 treatment days per disability, per calendar year

YES

30.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$55.00

100.00%
Specialty Drugs
YES

$300.00 Copay after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

30.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

30.00% Coinsurance after deductible

100.00%
Transplant
YES

30.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$50.00

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

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

30.00%

100.00%

CommunityCare Gold IH222 Health Insurance Plan Variant 98905OK0130044-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.782691109
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 Not Applicable
Disease Management Programs Offered Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pain Management
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID OKF004
Formulary URL URL
HIOS Product ID 98905OK013
Import Date 2/28/2023 1:02
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 Actuarial Value 78.40%
Issuer ID 98905
Issuer Marketplace Marketing Name CommunityCare
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 OKN001
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Services
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Services
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 98905OK0130044-00
Plan Marketing Name CommunityCare Gold IH222
Plan Type HMO
Plan Variant Marketing Name CommunityCare Gold IH222
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,100
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $2,200
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $100
SBC Scenario, Having Diabetes, Copayment $1,000
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $200
SBC Scenario, Treatment of a Simple Fracture, Copayment $60
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,200
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID OKS001
Source Name HIOS
Plan ID 98905OK0130044
State Code OK
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 30.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $6600 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $2200 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $2,200
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 Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of CommunityCare Gold IH222 Health Insurance Plan, 98905OK0130044

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

Frequently Asked Questions(FAQ) about CommunityCare Gold IH222, 98905OK0130044 Health Insurance Plan, 98905OK0130044

  • Does CommunityCare Gold IH222 Health Insurance Plan, 98905OK0130044 support Mail Ordering?

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

  • Does (98905OK0130044) Health Insurance Plan, Variant (98905OK0130044-00) offer Disease Management Programs?

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

    Does (98905OK0130044) Health Insurance Plan, Variant (98905OK0130044-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services

    Does (98905OK0130044) Health Insurance Plan, Variant (98905OK0130044-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services

    Does (98905OK0130044) Health Insurance Plan, Variant (98905OK0130044-00) offer Disease Management Programs?

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

    Does CommunityCare Gold IH222 Health Insurance Plan, Variant (98905OK0130044-00) offer Disease Management Programs for Heart disease?

    Yes, the CommunityCare Gold IH222 Health Insurance Plan Variant 98905OK0130044-00 offers Disease Management Program for Heart disease.

    Does CommunityCare Gold IH222 Health Insurance Plan, Variant (98905OK0130044-00) offer Disease Management Programs for Diabetes?

    Yes, the CommunityCare Gold IH222 Health Insurance Plan Variant 98905OK0130044-00 offers Disease Management Program for Diabetes.

    Does CommunityCare Gold IH222 Health Insurance Plan, Variant (98905OK0130044-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the CommunityCare Gold IH222 Health Insurance Plan Variant 98905OK0130044-00 offers Disease Management Program for High blood pressure & high cholesterol.

 

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