HMO Gold 3000 - 66966FL0050003 Health Insurance Plan

Capital Health Plan health insurance plan with the Plan ID 66966FL0050003. The plan is called HMO Gold 3000.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 76.26% (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 23.74% 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 66966FL0050003
Health Insurance Plan Year 2022
State Florida
Health Insurance Issuer Capital Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 66966FL0050003-03
Provider Network(s) ['FLN001']
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 Florida 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 - 66966FL0050003-00

Standard On Exchange Plan - 66966FL0050003-01

Open to Indians below 300% FPL - 66966FL0050003-02

Open to Indians above 300% FPL - 66966FL0050003-03

Last Plan Update Date Tue, 16 Nov 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

HMO Gold 3000 ($0 Preventive services/$0 Deductible/Vision/$0 Labs/$150 fitness reimbursement) Health Insurance Plan Variant 66966FL0050003-03 Attributes

Plan Attribute Value
AV Calculator Output Number 0.762593995
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Limited Cost Sharing Plan Variation
Dental Only Plan No
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes
EHB Percent of Total Premium 0.995520159
First Tier Utilization 79.03%
Formulary ID FLF003
Formulary URL URL
HIOS Product ID 66966FL005
Import Date 11/16/2021 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 5
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 66966
Issuer Marketplace Marketing Name Capital 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 Yes
National Network No
Network ID FLN001
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Care
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Urgent and Emergency Care
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 66966FL0050003-03
Plan Marketing Name HMO Gold 3000
Plan Type HMO
Plan Variant Marketing Name HMO Gold 3000 ($0 Preventive services/$0 Deductible/Vision/$0 Labs/$150 fitness reimbursement)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,600
SBC Scenario, Having a Baby, Copayment $1,400
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $2,000
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $1,300
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 20.97%
Service Area ID FLS001
Source Name HIOS
Plan ID 66966FL0050003
State Code FL
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $15800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $7900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $7,900
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $0
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 $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $0
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $0
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 $15800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,900
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $15800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $7900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $7,900
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 HMO Gold 3000 Health Insurance Plan, 66966FL0050003

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

Frequently Asked Questions(FAQ) about HMO Gold 3000, 66966FL0050003 Health Insurance Plan, 66966FL0050003

  • Does HMO Gold 3000 Health Insurance Plan, 66966FL0050003 support Mail Ordering?

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

  • Does (66966FL0050003) Health Insurance Plan, Variant (66966FL0050003-03) offer Disease Management Programs?

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

    Does (66966FL0050003) Health Insurance Plan, Variant (66966FL0050003-03) have Out Of Country Coverage?

    Yes. Details: Emergency Care

    Does (66966FL0050003) Health Insurance Plan, Variant (66966FL0050003-03) have Out of Service Area Coverage?

    Yes. Details: Urgent and Emergency Care

    Does (66966FL0050003) Health Insurance Plan, Variant (66966FL0050003-03) offer Disease Management Programs?

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

    Does HMO Gold 3000 ($0 Preventive services/$0 Deductible/Vision/$0 Labs/$150 fitness reimbursement) Health Insurance Plan, Variant (66966FL0050003-03) offer Disease Management Programs for Asthma?

    Yes, the HMO Gold 3000 ($0 Preventive services/$0 Deductible/Vision/$0 Labs/$150 fitness reimbursement) Health Insurance Plan Variant 66966FL0050003-03 offers Disease Management Program for Asthma.

    Does HMO Gold 3000 ($0 Preventive services/$0 Deductible/Vision/$0 Labs/$150 fitness reimbursement) Health Insurance Plan, Variant (66966FL0050003-03) offer Disease Management Programs for Heart disease?

    Yes, the HMO Gold 3000 ($0 Preventive services/$0 Deductible/Vision/$0 Labs/$150 fitness reimbursement) Health Insurance Plan Variant 66966FL0050003-03 offers Disease Management Program for Heart disease.

    Does HMO Gold 3000 ($0 Preventive services/$0 Deductible/Vision/$0 Labs/$150 fitness reimbursement) Health Insurance Plan, Variant (66966FL0050003-03) offer Disease Management Programs for Depression?

    Yes, the HMO Gold 3000 ($0 Preventive services/$0 Deductible/Vision/$0 Labs/$150 fitness reimbursement) Health Insurance Plan Variant 66966FL0050003-03 offers Disease Management Program for Depression.

    Does HMO Gold 3000 ($0 Preventive services/$0 Deductible/Vision/$0 Labs/$150 fitness reimbursement) Health Insurance Plan, Variant (66966FL0050003-03) offer Disease Management Programs for Diabetes?

    Yes, the HMO Gold 3000 ($0 Preventive services/$0 Deductible/Vision/$0 Labs/$150 fitness reimbursement) Health Insurance Plan Variant 66966FL0050003-03 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