Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 - 58840TX0110009 Health Insurance Plan

Aetna Health Inc. (a TX corp.) health insurance plan with the Plan ID 58840TX0110009. The plan is called Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 80.91% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.09% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 58840TX0110009
Health Insurance Plan Year 2023
State Texas
Health Insurance Issuer Aetna Health Inc. (a TX corp.)
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 58840TX0110009-00
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 - 58840TX0110009-00

Standard On Exchange Plan - 58840TX0110009-01

Open to Indians below 300% FPL - 58840TX0110009-02

Open to Indians above 300% FPL - 58840TX0110009-03

Last Plan Update Date Sat, 17 Dec 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan, 58840TX0110009-00

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

Exclusions: Member cost share based on place and type of service.

YES

$40.00

100.00%
Acupuncture

Limit: 10.0 Visit(s) per Year

Exclusions: Coverage is limited to 10 visits per calendar year.

YES

$20.00

100.00%
Allergy Testing

Exclusions: Member cost share based on place and type of service.

YES

$40.00

100.00%
Autism Spectrum Disorders

Exclusions: Member cost share based on place and type of service.

YES

$20.00

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

Exclusions: Member cost share based on place and type of service.

YES

20.00% Coinsurance after deductible

100.00%
Chemotherapy

Exclusions: Member cost share based on place and type of service.

YES

20.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 35.0 Visit(s) per Year

Exclusions: Coverage is limited to 35 visits per calendar year PT/OT/ST/Chiro combined. Benefit limits are separate for rehabilitation and habilitation services.

YES

20.00% Coinsurance after deductible

100.00%
Cosmetic Surgery

Exclusions: Covered only to correct conditions resulting from an accidental injury, gross anatomical defect present at birth or needed for the treatment of an illness.

NO
Delivery and All Inpatient Services for Maternity Care
YES

20.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Exclusions: Member cost share based on place and type of service.

YES

$40.00

100.00%
Dialysis

Exclusions: Member cost share based on place and type of service.

YES

20.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

50.00% Coinsurance after deductible

100.00%
Emergency Room Services

Exclusions: No coverage for non-emergency use of the emergency room.

YES

$750.00

$750.00
Emergency Transportation/Ambulance
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Exclusions: Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per calendar year.

YES

50.00% Coinsurance after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs

Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

$10.00

100.00%
Habilitation Services
YES

20.00% Coinsurance after deductible

100.00%
Hearing Aids
YES

50.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

Exclusions: Coverage is limited to 60 visits per calendar year

YES

20.00% Coinsurance after deductible

100.00%
Hospice Services

Exclusions: Member cost share based on place and type of service.

YES

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy

Exclusions: Member cost share based on place and type of service.

YES

20.00% Coinsurance after deductible

100.00%
Inherited Metabolic Disorder - PKU
YES

40.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

20.00% 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
YES

20.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$20.00

100.00%
Non-Preferred Brand Drugs

Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

40.00% Coinsurance after deductible

100.00%
Nutritional Counseling

Exclusions: Certain nutritional and diet counseling services are available to aid in weight reduction due to obesity, diabetes self management training, autism benefits, and for adults at higher risk of chronic disease.

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

$20.00

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

20.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 35.0 Visit(s) per Year

Exclusions: Coverage is limited to 35 visits per calendar year PT/OT/ST/Chiro combined. Benefit limits are separate for rehabilitation and habilitation services.

YES

20.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

$40.00 Copay after deductible

100.00%
Prenatal and Postnatal Care

Exclusions: Member cost sharing applies to postnatal care.

YES

20.00% Coinsurance after deductible

100.00%
Prescription Drugs Other

Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

40.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization

Exclusions: Age and frequency schedules may apply.

YES

No Charge

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

$20.00

100.00%
Private-Duty Nursing

Exclusions: Covered when medically necessary during an inpatient stay.

YES

50.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

50.00% Coinsurance after deductible

100.00%
Radiation

Exclusions: Member cost share based on place and type of service.

YES

20.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Exclusions: Member cost share based on place and type of service.

YES

20.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 35.0 Visit(s) per Year

Exclusions: Coverage is limited to 35 visits per calendar year PT/OT/ST/Chiro combined. Benefit limits are separate for rehabilitation and habilitation services.

YES

20.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 35.0 Visit(s) per Year

Exclusions: Coverage is limited to 35 visits per calendar year PT/OT/ST/Chiro combined. Benefit limits are separate for rehabilitation and habilitation services.

YES

20.00% Coinsurance after deductible

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

Limit: 1.0 Exam(s) per Year

Exclusions: Coverage is limited to 1 exam per 12 months.

YES

50.00% Coinsurance after deductible

100.00%
Routine Foot Care

Exclusions: Foot care for diabetics is covered.

NO
Skilled Nursing Facility

Limit: 25.0 Days per Year

Exclusions: Coverage is limited to 25 days per calendar year.

YES

20.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$40.00

100.00%
Specialty Drugs

Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$20.00

100.00%
Transplant

Exclusions: Member cost share based on place and type of service. Network benefits must be received within the transplant network.

YES

20.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Exclusions: Member cost share based on place and type of service. Excludes any non-surgical or non-diagnostic services or supplies.

YES

20.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$40.00

100.00%
Weight Loss Programs

Exclusions: Online weight loss programs are available.

NO
Well Baby Visits and Care

Exclusions: Coverage is limited 7 exams in the first 12 months of life; 3 exams in the second 12 months of life; 3 exams in the third 12 months of life; 1 exam per 12 months thereafter to age 22.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

20.00% Coinsurance after deductible

100.00%

Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan Variant 58840TX0110009-00 Attributes

Plan Attribute Value
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 Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID TXF009
Formulary URL URL
HIOS Product ID 58840TX011
Import Date 12/17/2022 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment 0
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? Yes
Issuer Actuarial Value 80.91%
Issuer ID 58840
Issuer Marketplace Marketing Name Aetna CVS Health
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 No
Out of Service Area Coverage No
Out of Service Area Coverage Description Except for Emergencies
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 58840TX0110009-00
Plan Marketing Name Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7
Plan Type HMO
Plan Variant Marketing Name Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,000
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $1,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $900
SBC Scenario, Having Diabetes, Deductible $1,500
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $700
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,300
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID TXS001
Source Name HIOS
Specialist Requiring a Referral Referral required for all physicians EXCEPT OB/GYN, ER, Internal Medicine, Family Practice, General Medicine and Pediatrician.
Plan ID 58840TX0110009
State Code TX
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 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $3000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,500
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 $14000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,000
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 Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan, 58840TX0110009

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

Frequently Asked Questions(FAQ) about Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7, 58840TX0110009 Health Insurance Plan, 58840TX0110009

  • Does Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan, 58840TX0110009 support Mail Ordering?

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

  • Does (58840TX0110009) Health Insurance Plan, Variant (58840TX0110009-00) 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

    Does (58840TX0110009) Health Insurance Plan, Variant (58840TX0110009-00) have Out Of Country Coverage?

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

    Does (58840TX0110009) Health Insurance Plan, Variant (58840TX0110009-00) 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: Except for Emergencies

    Does (58840TX0110009) Health Insurance Plan, Variant (58840TX0110009-00) 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

    Does Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan, Variant (58840TX0110009-00) offer Disease Management Programs for Asthma?

    Yes, the Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan Variant 58840TX0110009-00 offers Disease Management Program for Asthma.

    Does Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan, Variant (58840TX0110009-00) offer Disease Management Programs for Heart disease?

    Yes, the Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan Variant 58840TX0110009-00 offers Disease Management Program for Heart disease.

    Does Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan, Variant (58840TX0110009-00) offer Disease Management Programs for Depression?

    Yes, the Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan Variant 58840TX0110009-00 offers Disease Management Program for Depression.

    Does Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan, Variant (58840TX0110009-00) offer Disease Management Programs for Diabetes?

    Yes, the Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan Variant 58840TX0110009-00 offers Disease Management Program for Diabetes.

    Does Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan, Variant (58840TX0110009-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan Variant 58840TX0110009-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan, Variant (58840TX0110009-00) offer Disease Management Programs for Low back pain?

    Yes, the Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan Variant 58840TX0110009-00 offers Disease Management Program for Low back pain.

    Does Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan, Variant (58840TX0110009-00) offer Disease Management Programs for Pregnancy?

    Yes, the Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7 Health Insurance Plan Variant 58840TX0110009-00 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