KP Gold 2250/20/30/S9 - 89942GA0060018 Health Insurance Plan
Kaiser Foundation Health Plan of Georgia health insurance plan with the Plan ID 89942GA0060018. The plan is called KP Gold 2250/20/30/S9.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 80.15% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.85% 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 79.96% (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 20.04% 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 | 89942GA0060018 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Georgia | ||||||||||||||||||
| Health Insurance Issuer | Kaiser Foundation Health Plan of Georgia | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 89942GA0060018-00 | ||||||||||||||||||
| Provider Network(s) | ['GAN001'] | ||||||||||||||||||
| 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 | |||||||||||||||||||
| Last Plan Update Date | Sat, 20 Nov 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
KP Gold 2250/20/30/S9 Health Insurance Plan Variant 89942GA0060018-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.79960799 |
| 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 | 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 | 25.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $500 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $250 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $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 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| First Tier Utilization | 100% |
| Formulary ID | GAF004 |
| Formulary URL | URL |
| HIOS Product ID | 89942GA006 |
| HSA/HRA Employer Contribution | No |
| Import Date | 11/20/2021 2:46 |
| 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 | 80.15% |
| Issuer ID | 89942 |
| Issuer Marketplace Marketing Name | Kaiser Permanente |
| Market Coverage | SHOP (Small Group) |
| 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 | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $4500 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $2250 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $2,250 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | GAN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Urgent and Emergency Care Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Urgent and Emergency Care Only |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 89942GA0060018-00 |
| Plan Marketing Name | KP Gold 2250/20/30/S9 |
| Plan Type | HMO |
| Plan Variant Marketing Name | KP Gold 2250/20/30/S9 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,800 |
| SBC Scenario, Having a Baby, Copayment | $100 |
| SBC Scenario, Having a Baby, Deductible | $2,250 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,200 |
| SBC Scenario, Having Diabetes, Deductible | $250 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| 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 | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | GAS001 |
| Source Name | HIOS |
| Specialist Requiring a Referral | Allergy & Immunology, Anesthesiology, Audiology, Cardiology, Colon & Rectal Surgery, Critical Care Medicine, Endocrinology/Metabolism, Gastroenterology, General Surgery, Gynecologic Oncology, Hand Surgery, Hematology, Hematology/Oncology, Hyperbaric Medicine, Infectious Diseases, Infertility, Maternal & Fetal Medicine, Nephrology, Neurology, Neurosurgery, Occupational Therapy, Oncology, Oral & Maxillofacial Surgery, Otolaryngology, Pain Management, Pediatric Cardiology, Pediatric Endocrinology, Pediatric Gastroenterology, Pediatric Hematology/Oncology, Pediatric Infectious Diseases, Pediatric Nephrology, Pediatric Neurology, Pediatric Neurosurgery, Pediatric Otolaryngology, Pediatric Pulmonology, Pediatric Surgery, Pediatric Urology, Physical Medicine & Rehabilitation, Physical Therapy, Plastic Surgery, Podiatry, Pulmonary Disease, Radiation Oncology, Sleep Disorders, Sports Medicine, Thoracic Surgery, Urology and Vascular Surgery |
| Plan ID | 89942GA0060018 |
| State Code | GA |
| 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 | $16300 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8150 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,150 |
| 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 | No |
Copay & Coinsurance of KP Gold 2250/20/30/S9 Health Insurance Plan, 89942GA0060018
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about KP Gold 2250/20/30/S9, 89942GA0060018 Health Insurance Plan, 89942GA0060018
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Does KP Gold 2250/20/30/S9 Health Insurance Plan, 89942GA0060018 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (89942GA0060018) Health Insurance Plan, Variant (89942GA0060018-00) 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 (89942GA0060018) Health Insurance Plan, Variant (89942GA0060018-00) have Out Of Country Coverage?
Yes. Details: Urgent and Emergency Care Only
Does (89942GA0060018) Health Insurance Plan, Variant (89942GA0060018-00) have Out of Service Area Coverage?
Yes. Details: Urgent and Emergency Care Only
Does (89942GA0060018) Health Insurance Plan, Variant (89942GA0060018-00) 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 KP Gold 2250/20/30/S9 Health Insurance Plan, Variant (89942GA0060018-00) offer Disease Management Programs for Asthma?
Yes, the KP Gold 2250/20/30/S9 Health Insurance Plan Variant
89942GA0060018-00 offers Disease
Management Program for Asthma.
Does KP Gold 2250/20/30/S9 Health Insurance Plan, Variant (89942GA0060018-00) offer Disease Management Programs for Heart disease?
Yes, the KP Gold 2250/20/30/S9 Health Insurance Plan Variant
89942GA0060018-00 offers Disease
Management Program for Heart disease.
Does KP Gold 2250/20/30/S9 Health Insurance Plan, Variant (89942GA0060018-00) offer Disease Management Programs for Depression?
Yes, the KP Gold 2250/20/30/S9 Health Insurance Plan Variant
89942GA0060018-00 offers Disease
Management Program for Depression.
Does KP Gold 2250/20/30/S9 Health Insurance Plan, Variant (89942GA0060018-00) offer Disease Management Programs for Diabetes?
Yes, the KP Gold 2250/20/30/S9 Health Insurance Plan Variant
89942GA0060018-00 offers Disease
Management Program for Diabetes.
Does KP Gold 2250/20/30/S9 Health Insurance Plan, Variant (89942GA0060018-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the KP Gold 2250/20/30/S9 Health Insurance Plan Variant
89942GA0060018-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does KP Gold 2250/20/30/S9 Health Insurance Plan, Variant (89942GA0060018-00) offer Disease Management Programs for Low back pain?
Yes, the KP Gold 2250/20/30/S9 Health Insurance Plan Variant
89942GA0060018-00 offers Disease
Management Program for Low back pain.
Does KP Gold 2250/20/30/S9 Health Insurance Plan, Variant (89942GA0060018-00) offer Disease Management Programs for Pregnancy?
Yes, the KP Gold 2250/20/30/S9 Health Insurance Plan Variant
89942GA0060018-00 offers Disease
Management Program for Pregnancy.
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