HA Gold Plan 2 - 13262AR0230003 Health Insurance Plan
HMO Partners, Inc. health insurance plan with the Plan ID 13262AR0230003. The plan is called HA Gold Plan 2.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.59% (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 21.41% 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 | 13262AR0230003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Arkansas | ||||||||||||||||||
| Health Insurance Issuer | HMO Partners, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 13262AR0230003-00 | ||||||||||||||||||
| Provider Network(s) | ['ARN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 13262AR0230003-00 Standard On Exchange Plan - 13262AR0230003-01 |
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| Last Plan Update Date | Mon, 15 Aug 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of HA Gold Plan 2 Health Insurance Plan, 13262AR0230003-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 40.00% |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
SOB includes 'allergy services.' |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Applied Behavior Analysis Based Therapies
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $30.00 |
100.00% |
| Cochlear Implants
Requires Prior Approval from Health Advantage. One cochlear implant per ear per Covered Person per lifetime |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Craniofacial Surgery
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services: 13262AR0230003-01-40% Coinsurance for in-network services and 50% Coinsurance after deductible for out-of-network services; 13262AR0230003-02-No charge for in-network and out-of-network services; 13262AR0230003-03-40% Coinsurance for in-network services and 50% Coinsurance after deductible for out-of-network services; Coverage for Out of Network newborn services is limited to $2000 per person for all services first 90 days after birth. Coverage requires Prior Notification to Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Dental Anesthesia
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | 40.00% |
50.00% Coinsurance after deductible |
| Diabetes Education
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Dialysis
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
Requires Prior Approval from Health Advantage for services $500 or more |
YES | 50.00% |
50.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | $350.00 |
$350.00 |
| Emergency Transportation/Ambulance
|
YES | 40.00% |
40.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Gastric Electrical Stimulation
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Gender Affirming Care
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
100.00% |
| Generic Drugs
|
YES | $25.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro; Limited to a maximum of 180 units for developmental services visits per Covered Person per calendar year. |
YES | $30.00 |
100.00% |
| Hearing Aids
Coverage is limited to $1400/ear |
YES | No Charge |
No Charge |
| Home Health Care Services
Limit: 50.0 Visit(s) per Year Requires Prior Approval from Health Advantage. Coverage is provided for Home Health Services when Coverage Policy supports the need for in-home service and such care is prescribed or ordered by a Physician. Covered Services must be provided through and billed by a licensed home health agency. Covered Services provided in the home include services of a Registered Professional Nurse (R.N.), a Licensed Practical Nurse (L.P.N.) or a Licensed Psychiatric Technical Nurse (L.P.T.N.). |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Hospice Services
Requires Prior Approval from Health Advantage. If the Covered Person has been diagnosed and certified by the attending Physician as having a terminal illness with a life expectancy of six months or less, Health Advantage will pay the Allowance or Allowable Charge for Hospice Care. The services must be rendered by an entity licensed by the Arkansas Department of Health or other appropriate state licensing agency and accepted by Health Advantage as a Provider. This benefit is subject to the Deductible, Copayment and Coinsurance specified in the Schedule of Benefits. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
Requires Prior Approval from Health Advantage for high tech radiology services |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Home infusion therapy. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Inherited Metabolic Disorder - PKU
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
Requires Prior Approval from Health Advantage. |
YES | $500.00 Copay per Day |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | $50.00 |
50.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Requires Prior Approval from Health Advantage. |
YES | $500.00 Copay per Day |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
|
YES | $100.00 Copay after deductible |
100.00% |
| Nutritional Counseling
Coverage is provided for dietary and nutritional counseling services when provided in conjunction with diabetic self-management training, for services needed by covered persons in connection with cleft palate management and for nutritional assessment programs provided in and by a hospital and approved by Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Off Label Prescription Drugs
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $30.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
|
YES | $40.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
Requires Prior Notification to Health Advantage. Coverage for routine ultrasound is limited to 1. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Preventive Drugs
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Requires Prior Approval from Health Advantage for any device for which cost exceeds $5,000. Replaced no more frequently than once per 3-yr period except when necessary for growth or end of device's useful life. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Radiation
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
Requires Prior Approval from Health Advantage. 1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Covered Person; 2. Surgery performed for the removal of a port-wine stain or hemangioma (only on the face) 3. Treatment provided for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria and is Prior Approved by Health Advantage is covered. |
YES | 40.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $30.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per 2 Years |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
YES | 40.00% |
50.00% Coinsurance after deductible |
| Skilled Nursing Facility
Limit: 60.0 Days per Year Requires Prior Approval from Health Advantage. 1. The admission must be within seven days of release from an inpatient Hospital stay; 2. The Skilled Nursing Facility services are of a temporary nature and increase ability to function. |
YES | $500.00 Copay per Day |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| Specialty Drugs
Requires Prior Approval from Health Advantage. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Specialty Drugs Tier 2
Requires Prior Approval from Health Advantage. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Requires Prior Approval from Health Advantage. |
YES | $500.00 Copay per Day |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Transplant
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
Requires Prior Approval from Health Advantage. |
YES | 40.00% |
50.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
|
YES | $80.00 |
50.00% Coinsurance after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| Well Child Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 40.00% |
50.00% Coinsurance after deductible |
HA Gold Plan 2 Health Insurance Plan Variant 13262AR0230003-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.785913989 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 2 |
| 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 |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 40.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $2500 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1250 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $1,250 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| 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 | 0.9999 |
| First Tier Utilization | 100% |
| Formulary ID | ARF001 |
| Formulary URL | URL |
| HIOS Product ID | 13262AR023 |
| Import Date | 8/15/2022 20:01 |
| 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 | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 13262 |
| Issuer Marketplace Marketing Name | Health Advantage |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 40.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | $18000 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $9000 per person |
| Medical EHB Deductible, Out of Network, Individual | $9,000 |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | ARN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Care |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Benefit Reduction |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 13262AR0230003-00 |
| Plan Level Exclusions | No |
| Plan Marketing Name | HA Gold Plan 2 |
| Plan Type | POS |
| Plan Variant Marketing Name | HA Gold Plan 2 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $5,100 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $40 |
| SBC Scenario, Having a Baby, Limit | $40 |
| SBC Scenario, Having Diabetes, Coinsurance | $1,000 |
| SBC Scenario, Having Diabetes, Copayment | $800 |
| SBC Scenario, Having Diabetes, Deductible | $1,300 |
| SBC Scenario, Having Diabetes, Limit | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $700 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ARS001 |
| Source Name | SERFF |
| Plan ID | 13262AR0230003 |
| State Code | AR |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $15000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $34000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $17000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $17,000 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of HA Gold Plan 2 Health Insurance Plan, 13262AR0230003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about HA Gold Plan 2, 13262AR0230003 Health Insurance Plan, 13262AR0230003
-
Does HA Gold Plan 2 Health Insurance Plan, 13262AR0230003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (13262AR0230003) Health Insurance Plan, Variant (13262AR0230003-00) offer Disease Management Programs?
Does (13262AR0230003) Health Insurance Plan, Variant (13262AR0230003-00) have Out Of Country Coverage?
Does (13262AR0230003) Health Insurance Plan, Variant (13262AR0230003-00) have Out of Service Area Coverage?
Does (13262AR0230003) Health Insurance Plan, Variant (13262AR0230003-00) offer Disease Management Programs?
Does HA Gold Plan 2 Health Insurance Plan, Variant (13262AR0230003-00) offer Disease Management Programs for Asthma?
Does HA Gold Plan 2 Health Insurance Plan, Variant (13262AR0230003-00) offer Disease Management Programs for Heart disease?
Does HA Gold Plan 2 Health Insurance Plan, Variant (13262AR0230003-00) offer Disease Management Programs for Depression?
Does HA Gold Plan 2 Health Insurance Plan, Variant (13262AR0230003-00) offer Disease Management Programs for Diabetes?
Does HA Gold Plan 2 Health Insurance Plan, Variant (13262AR0230003-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does HA Gold Plan 2 Health Insurance Plan, Variant (13262AR0230003-00) offer Disease Management Programs for Low back pain?
Does HA Gold Plan 2 Health Insurance Plan, Variant (13262AR0230003-00) offer Disease Management Programs for Pregnancy?
Does HA Gold Plan 2 Health Insurance Plan, Variant (13262AR0230003-00) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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