KP GA Standard Silver 5800/40 - 89942GA0130003 Health Insurance Plan

Kaiser Foundation Health Plan of Georgia health insurance plan with the Plan ID 89942GA0130003. The plan is called KP GA Standard Silver 5800/40.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.06% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.94% 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 70.06% (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 29.94% 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 89942GA0130003
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 89942GA0130003-00
Provider Network(s) ['GAN003']
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 - 89942GA0130003-00

Standard On Exchange Plan - 89942GA0130003-01

Open to Indians below 300% FPL - 89942GA0130003-02

Open to Indians above 300% FPL - 89942GA0130003-03

73% AV Silver Plan - 89942GA0130003-04

87% AV Silver Plan - 89942GA0130003-05

94% AV Silver Plan - 89942GA0130003-06

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

Benefits of KP GA Standard Silver 5800/40 Health Insurance Plan, 89942GA0130003-00

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

40.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing

Services performed in an outpatient hospital setting are usually at a greater member cost share.

YES

$80.00

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

40.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

Coverage limited to Spinal Manipulation.

YES

$40.00

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

40.00% Coinsurance after deductible

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

$80.00

100.00%
Dialysis
YES

40.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

40.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
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 and Tier 2 generics @ cost share shown. Non-preferred generics @ non-preferred brand cost share. Up to a 90 day supply is available through mail order

YES

$20.00

100.00%
Habilitation Services
YES

$40.00

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

40.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$40.00

100.00%
Non-Preferred Brand Drugs

Up to a 90 day supply is available through mail order

YES

$80.00 Copay after deductible

100.00%
Nutritional Counseling
YES

$80.00

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

$40.00

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

40.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Please refer to Plan Brochure and SBC.

YES

$40.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Up to a 90 day supply is available through mail order

YES

$40.00

100.00%
Prenatal and Postnatal Care
YES

40.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

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

$40.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

40.00% Coinsurance after deductible

100.00%
Radiation
YES

40.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

With limitations

YES

40.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Year

40 visit limit per year for PT and OT combined

YES

$40.00

100.00%
Rehabilitative Speech Therapy

Limit: 40.0 Visit(s) per Year

YES

$40.00

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

Limit: 1.0 Exam(s) per Year

YES

$40.00

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

$40.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 150.0 Days per Year

YES

40.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$80.00

100.00%
Specialty Drugs
YES

$350.00 Copay after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

40.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$40.00

100.00%
Transplant
YES

40.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

40.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$60.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care

Care provided for children from birth through age 5.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

40.00% Coinsurance after deductible

100.00%

KP GA Standard Silver 5800/40 Health Insurance Plan Variant 89942GA0130003-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7006
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 Silver Off Exchange Plan
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
EHB Percent of Total Premium 0.999
First Tier Utilization 100%
Formulary ID GAF037
Formulary URL URL
HIOS Product ID 89942GA013
Import Date 2/24/2023 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? Yes
Issuer Actuarial Value 70.06%
Issuer ID 89942
Issuer Marketplace Marketing Name Kaiser Permanente
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID GAN003
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) 89942GA0130003-00
Plan Marketing Name KP GA Standard Silver 5800/40
Plan Type HMO
Plan Variant Marketing Name KP GA Standard Silver 5800/40
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,700
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $5,800
SBC Scenario, Having a Baby, Limit $50
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,500
SBC Scenario, Having Diabetes, Deductible $90
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,200
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID GAS002
Source Name HIOS
Specialist Requiring a Referral All specialists except Dermatology, Behavioral Health, Optometry, Ophthamology, Obestetrical and Gynecology require a referral.
Plan ID 89942GA0130003
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
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $11600 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5800 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,800
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 $17800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,900
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 Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of KP GA Standard Silver 5800/40 Health Insurance Plan, 89942GA0130003

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

Frequently Asked Questions(FAQ) about KP GA Standard Silver 5800/40, 89942GA0130003 Health Insurance Plan, 89942GA0130003

  • Does KP GA Standard Silver 5800/40 Health Insurance Plan, 89942GA0130003 support Mail Ordering?

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

  • Does (89942GA0130003) Health Insurance Plan, Variant (89942GA0130003-00) 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 (89942GA0130003) Health Insurance Plan, Variant (89942GA0130003-00) have Out Of Country Coverage?

    Yes. Details: Urgent and Emergency Care only

    Does (89942GA0130003) Health Insurance Plan, Variant (89942GA0130003-00) have Out of Service Area Coverage?

    Yes. Details: Urgent and Emergency Care only

    Does (89942GA0130003) Health Insurance Plan, Variant (89942GA0130003-00) 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 GA Standard Silver 5800/40 Health Insurance Plan, Variant (89942GA0130003-00) offer Disease Management Programs for Asthma?

    Yes, the KP GA Standard Silver 5800/40 Health Insurance Plan Variant 89942GA0130003-00 offers Disease Management Program for Asthma.

    Does KP GA Standard Silver 5800/40 Health Insurance Plan, Variant (89942GA0130003-00) offer Disease Management Programs for Heart disease?

    Yes, the KP GA Standard Silver 5800/40 Health Insurance Plan Variant 89942GA0130003-00 offers Disease Management Program for Heart disease.

    Does KP GA Standard Silver 5800/40 Health Insurance Plan, Variant (89942GA0130003-00) offer Disease Management Programs for Depression?

    Yes, the KP GA Standard Silver 5800/40 Health Insurance Plan Variant 89942GA0130003-00 offers Disease Management Program for Depression.

    Does KP GA Standard Silver 5800/40 Health Insurance Plan, Variant (89942GA0130003-00) offer Disease Management Programs for Diabetes?

    Yes, the KP GA Standard Silver 5800/40 Health Insurance Plan Variant 89942GA0130003-00 offers Disease Management Program for Diabetes.

    Does KP GA Standard Silver 5800/40 Health Insurance Plan, Variant (89942GA0130003-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the KP GA Standard Silver 5800/40 Health Insurance Plan Variant 89942GA0130003-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does KP GA Standard Silver 5800/40 Health Insurance Plan, Variant (89942GA0130003-00) offer Disease Management Programs for Low back pain?

    Yes, the KP GA Standard Silver 5800/40 Health Insurance Plan Variant 89942GA0130003-00 offers Disease Management Program for Low back pain.

    Does KP GA Standard Silver 5800/40 Health Insurance Plan, Variant (89942GA0130003-00) offer Disease Management Programs for Pregnancy?

    Yes, the KP GA Standard Silver 5800/40 Health Insurance Plan Variant 89942GA0130003-00 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