KP Gold 0/0/30/S10 - 89942GA0060002 Health Insurance Plan

Kaiser Foundation Health Plan of Georgia health insurance plan with the Plan ID 89942GA0060002. The plan is called KP Gold 0/0/30/S10.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.97% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.03% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 89942GA0060002
Health Insurance Plan Year 2023
State Georgia
Health Insurance Issuer Kaiser Foundation Health Plan of Georgia
Plan Formulary Description URL Formulary URL
Health Insurance Plan Variant 89942GA0060002-00
Provider Network(s) ['GAN001']
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 Georgia 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 - 89942GA0060002-00

Standard On Exchange Plan - 89942GA0060002-01

Last Plan Update Date Fri, 24 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of KP Gold 0/0/30/S10 Health Insurance Plan, 89942GA0060002-00

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

40.00%

100.00%
Acupuncture
NO
Allergy Testing
YES

$60.00

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

$60.00

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

Coverage limited to Spinal Manipulation.

YES

$60.00

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

Copay charged per day until Out of Pocket Maximum is met.

YES

$800.00

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

$60.00

100.00%
Dialysis
YES

$60.00

100.00%
Durable Medical Equipment
YES

30.00%

100.00%
Emergency Room Services
YES

$550.00

$550.00
Emergency Transportation/Ambulance
YES

$550.00

$550.00
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Frames from a specified Collection

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

Tier 1 generics available at lower cost share. Tier 2 generics at cost share shown. Non-preferred generics see non-preferred brand cost share. Greater member cost share at network pharmacies. Network pharmacies can only be used for initial prescription fills.

YES

$10.00

100.00%
Habilitation Services

Visit limits may apply. Please refer to Plan Brochure and SBC.

YES

$60.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 120.0 Visit(s) per Year

YES

No Charge

100.00%
Hospice Services
YES

No Charge

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

$400.00

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

$60.00

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

Copay charged per day until Out of Pocket Maximum is met.

YES

$800.00 Copay per Day

100.00%
Inpatient Physician and Surgical Services
YES

No Charge

100.00%
Laboratory Outpatient and Professional Services
YES

No Charge

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

Copay charged per day until Out of Pocket Maximum is met.

YES

$800.00 Copay per Day

100.00%
Mental/Behavioral Health Outpatient Services
YES

$30.00

100.00%
Non-Preferred Brand Drugs

Greater member cost share at network pharmacies. Network pharmacies can only be used for initial prescription fills.

YES

$80.00

100.00%
Nutritional Counseling
YES

$60.00

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

$30.00

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

$550.00

100.00%
Outpatient Rehabilitation Services

Visit limits may apply. Please refer to Plan Brochure and SBC.

YES

$60.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge

100.00%
Preferred Brand Drugs

Greater member cost share at network pharmacies. Network pharmacies can only be used for initial prescription fills.

YES

$50.00

100.00%
Prenatal and Postnatal Care
YES

No Charge

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

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

$30.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

30.00%

100.00%
Radiation
YES

$60.00

100.00%
Reconstructive Surgery

If inpatient, copay charged per day until Out of Pocket Maximum is met. With limitations

YES

$800.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Year

YES

$60.00

100.00%
Rehabilitative Speech Therapy

Limit: 40.0 Visit(s) per Year

YES

$60.00

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

Limit: 1.0 Exam(s) per Year

YES

$30.00

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

$30.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 150.0 Days per Year

Copay charged per day until Out of Pocket Maximum is met.

YES

$800.00 Copay per Day

100.00%
Specialist Visit
YES

$60.00

100.00%
Specialty Drugs

Network pharmacies can only be used for initial prescription fills.

YES

35.00%

100.00%
Substance Abuse Disorder Inpatient Services

Copay charged per day until Out of Pocket Maximum is met.

YES

$800.00 Copay per Day

100.00%
Substance Abuse Disorder Outpatient Services
YES

$30.00

100.00%
Transplant

Copay charged per day until Out of Pocket Maximum is met.

YES

$800.00

100.00%
Treatment for Temporomandibular Joint Disorders
YES

40.00%

100.00%
Urgent Care Centers or Facilities
YES

$60.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care

Care provided for birth through age 5.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$20.00

100.00%

KP Gold 0/0/30/S10 Health Insurance Plan Variant 89942GA0060002-00 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
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 35.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group per group not applicable
Drug EHB Deductible, In Network (Tier 1), Family Per Person per person not applicable
Drug EHB Deductible, In Network (Tier 1), Individual $0
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 GAF002
Formulary URL URL
HIOS Product ID 89942GA006
HSA/HRA Employer Contribution No
Import Date 2/24/2023 1:01
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 81.97%
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 0.00%
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 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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 89942GA0060002-00
Plan Marketing Name KP Gold 0/0/30/S10
Plan Type HMO
Plan Variant Marketing Name KP Gold 0/0/30/S10
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $900
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $50
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,300
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $100
SBC Scenario, Treatment of a Simple Fracture, Copayment $1,400
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID GAS001
Source Name HIOS
Specialist Requiring a Referral All specialists except Dermatology, Behavioral Health, Optometry, Ophthamology, Obestetrical and Gynecology require a referral.
Plan ID 89942GA0060002
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 $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
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 0/0/30/S10 Health Insurance Plan, 89942GA0060002

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

Frequently Asked Questions(FAQ) about KP Gold 0/0/30/S10, 89942GA0060002 Health Insurance Plan, 89942GA0060002

  • Does KP Gold 0/0/30/S10 Health Insurance Plan, 89942GA0060002 support Mail Ordering?

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

  • Does (89942GA0060002) Health Insurance Plan, Variant (89942GA0060002-00) 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 (89942GA0060002) Health Insurance Plan, Variant (89942GA0060002-00) have Out Of Country Coverage?

    Yes. Details: Urgent and Emergency Care Only

    Does (89942GA0060002) Health Insurance Plan, Variant (89942GA0060002-00) have Out of Service Area Coverage?

    Yes. Details: Urgent and Emergency Care Only

    Does (89942GA0060002) Health Insurance Plan, Variant (89942GA0060002-00) 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 0/0/30/S10 Health Insurance Plan, Variant (89942GA0060002-00) offer Disease Management Programs for Asthma?

    Yes, the KP Gold 0/0/30/S10 Health Insurance Plan Variant 89942GA0060002-00 offers Disease Management Program for Asthma.

    Does KP Gold 0/0/30/S10 Health Insurance Plan, Variant (89942GA0060002-00) offer Disease Management Programs for Heart disease?

    Yes, the KP Gold 0/0/30/S10 Health Insurance Plan Variant 89942GA0060002-00 offers Disease Management Program for Heart disease.

    Does KP Gold 0/0/30/S10 Health Insurance Plan, Variant (89942GA0060002-00) offer Disease Management Programs for Depression?

    Yes, the KP Gold 0/0/30/S10 Health Insurance Plan Variant 89942GA0060002-00 offers Disease Management Program for Depression.

    Does KP Gold 0/0/30/S10 Health Insurance Plan, Variant (89942GA0060002-00) offer Disease Management Programs for Diabetes?

    Yes, the KP Gold 0/0/30/S10 Health Insurance Plan Variant 89942GA0060002-00 offers Disease Management Program for Diabetes.

    Does KP Gold 0/0/30/S10 Health Insurance Plan, Variant (89942GA0060002-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the KP Gold 0/0/30/S10 Health Insurance Plan Variant 89942GA0060002-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does KP Gold 0/0/30/S10 Health Insurance Plan, Variant (89942GA0060002-00) offer Disease Management Programs for Low back pain?

    Yes, the KP Gold 0/0/30/S10 Health Insurance Plan Variant 89942GA0060002-00 offers Disease Management Program for Low back pain.

    Does KP Gold 0/0/30/S10 Health Insurance Plan, Variant (89942GA0060002-00) offer Disease Management Programs for Pregnancy?

    Yes, the KP Gold 0/0/30/S10 Health Insurance Plan Variant 89942GA0060002-00 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