Capital Health Plan HMO Platinum 4000 - 66966FL0050008 Health Insurance Plan

Capital Health Plan health insurance plan with the Plan ID 66966FL0050008. The plan is called Capital Health Plan HMO Platinum 4000.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 88.00% (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 12.00% 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 66966FL0050008
Health Insurance Plan Year 2023
State Florida
Health Insurance Issuer Capital Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 66966FL0050008-00
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 - 66966FL0050008-00

Standard On Exchange Plan - 66966FL0050008-01

Open to Indians below 300% FPL - 66966FL0050008-02

Open to Indians above 300% FPL - 66966FL0050008-03

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

Benefits of Capital Health Plan HMO Platinum 4000 Health Insurance Plan, 66966FL0050008-00

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

$350.00

100.00%
Acupuncture
NO
Allergy Testing
YES

$20.00

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

$150.00

100.00%
Chiropractic Care

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

YES

$10.00

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

per Provider

YES

$350.00

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

No Charge

100.00%
Dialysis
YES

No Charge

100.00%
Durable Medical Equipment
YES

No Charge

100.00%
Emergency Room Services

Coinsurance and Copayment is waived if inpatient admission occurs; however if moved to observation status an additional copayment may apply based on services rendered.

YES

$100.00

$100.00
Emergency Transportation/Ambulance
YES

$100.00

$100.00
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Provided at Capital Health Plan's Eye Care Centers

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

$5.00

100.00%
Habilitation Services

Limit: 35.0 Visit(s) per Benefit Period

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

YES

$10.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 20.0 Days per Benefit Period

YES

$10.00

100.00%
Hospice Services
YES

No Charge

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

$100.00

100.00%
Infertility Treatment
NO
Infusion Therapy
NO
Inpatient Hospital Services (e.g., Hospital Stay)
YES

$350.00 Copay per Stay

100.00%
Inpatient Physician and Surgical Services

per Provider

YES

$350.00

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

$350.00 Copay per Stay

100.00%
Mental/Behavioral Health Outpatient Services

Non-Office Mental Health visit cost share will align with Outpatient Facility Fee cost share

YES

$10.00

100.00%
Non-Preferred Brand Drugs
YES

$50.00

100.00%
Nutritional Counseling

Diabetes coverage includes 'nutrition counseling'; home health services include 'nutritional guidance.'

YES

$20.00

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

$10.00

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

$150.00

100.00%
Outpatient Rehabilitation Services

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

YES

$10.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$150.00

100.00%
Preferred Brand Drugs
YES

$10.00

100.00%
Prenatal and Postnatal Care
YES

$20.00

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

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

$10.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

No Charge

100.00%
Radiation
YES

$150.00

100.00%
Reconstructive Surgery

Only for Breast reconstruction following a Mastectomy.

YES

$350.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

YES

$10.00

100.00%
Rehabilitative Speech Therapy

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

YES

$10.00

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

Limit: 1.0 Exam(s) per Year

Provided at Capital Health Plan's Eye Care Centers

YES

$20.00

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

Provided at Capital Health Plan's Eye Care Centers

YES

$20.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

YES

$150.00 Copay per Stay

100.00%
Specialist Visit
YES

$20.00

100.00%
Specialty Drugs
YES

$150.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

$350.00 Copay per Stay

100.00%
Substance Abuse Disorder Outpatient Services

Non-Office Substance Use Disorder visit cost share will align with Outpatient Facility Fee cost share

YES

$10.00

100.00%
Transplant
YES

$350.00

100.00%
Treatment for Temporomandibular Joint Disorders
YES

$350.00

100.00%
Urgent Care Centers or Facilities
YES

$15.00

$15.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$30.00

100.00%

Capital Health Plan HMO Platinum 4000 (Wellness Program $$$) Health Insurance Plan Variant 66966FL0050008-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.880035748
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 Platinum Off Exchange Plan
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes
EHB Percent of Total Premium 0.998402556
First Tier Utilization 100%
Formulary ID FLF006
Formulary URL URL
HIOS Product ID 66966FL005
Import Date 8/17/2022 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
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 Platinum
Multiple In Network Tiers No
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 Emergenct Care
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 66966FL0050008-00
Plan Marketing Name Capital Health Plan HMO Platinum 4000
Plan Type HMO
Plan Variant Marketing Name Capital Health Plan HMO Platinum 4000 (Wellness Program $$$)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $1,500
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 $2,300
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 $700
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID FLS001
Source Name HIOS
Plan ID 66966FL0050008
State Code FL
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $6000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $3000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $3,000
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 50.00%
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, 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 $6000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $3000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $3,000
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 No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Capital Health Plan HMO Platinum 4000 Health Insurance Plan, 66966FL0050008

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

Frequently Asked Questions(FAQ) about Capital Health Plan HMO Platinum 4000, 66966FL0050008 Health Insurance Plan, 66966FL0050008

  • Does Capital Health Plan HMO Platinum 4000 Health Insurance Plan, 66966FL0050008 support Mail Ordering?

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

  • Does (66966FL0050008) Health Insurance Plan, Variant (66966FL0050008-00) offer Disease Management Programs?

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

    Does (66966FL0050008) Health Insurance Plan, Variant (66966FL0050008-00) have Out Of Country Coverage?

    Yes. Details: Emergency Care

    Does (66966FL0050008) Health Insurance Plan, Variant (66966FL0050008-00) have Out of Service Area Coverage?

    Yes. Details: Urgent and Emergenct Care

    Does (66966FL0050008) Health Insurance Plan, Variant (66966FL0050008-00) offer Disease Management Programs?

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

    Does Capital Health Plan HMO Platinum 4000 (Wellness Program $$$) Health Insurance Plan, Variant (66966FL0050008-00) offer Disease Management Programs for Asthma?

    Yes, the Capital Health Plan HMO Platinum 4000 (Wellness Program $$$) Health Insurance Plan Variant 66966FL0050008-00 offers Disease Management Program for Asthma.

    Does Capital Health Plan HMO Platinum 4000 (Wellness Program $$$) Health Insurance Plan, Variant (66966FL0050008-00) offer Disease Management Programs for Heart disease?

    Yes, the Capital Health Plan HMO Platinum 4000 (Wellness Program $$$) Health Insurance Plan Variant 66966FL0050008-00 offers Disease Management Program for Heart disease.

    Does Capital Health Plan HMO Platinum 4000 (Wellness Program $$$) Health Insurance Plan, Variant (66966FL0050008-00) offer Disease Management Programs for Depression?

    Yes, the Capital Health Plan HMO Platinum 4000 (Wellness Program $$$) Health Insurance Plan Variant 66966FL0050008-00 offers Disease Management Program for Depression.

    Does Capital Health Plan HMO Platinum 4000 (Wellness Program $$$) Health Insurance Plan, Variant (66966FL0050008-00) offer Disease Management Programs for Diabetes?

    Yes, the Capital Health Plan HMO Platinum 4000 (Wellness Program $$$) Health Insurance Plan Variant 66966FL0050008-00 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