AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards

67926FL0010004
Gold
HMO

AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards is a Gold HMO plan by AmeriHealth Caritas Next.

IMPORTANT: You are viewing the 2023 version of AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards 67926FL0010004. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards 67926FL0010004.
Insurer: AmeriHealth Caritas Next
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 67926FL0010004

Cost-Sharing Overview

AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Diabetes, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description:
National Network: No

Additional Benefits and Cost-Sharing

AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 100.00%
Specialist Visit
Covered
$60.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
25.00% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$45.00 100.00%
Home Health Care Services
Covered
25.00% Coinsurance after deductible 100.00%20 Days per Benefit Period Part-time- Services limited to less than 8 hours a day, less than 40 hours a week. Intermittent- Services limited to each visit up to but not exceeding 2 hours a day. Excluded: Services rendered by an employee/operator of an adult congregate living facility, adult foster home, adult day care center, or a nursing facility.
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 100.00%60 Days per Benefit Period
Prenatal and Postnatal Care
Covered
25.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 100.00% Maternity services rendered to a covered person who is acting as a gestational surrogate are excluded and for services related to surrogate parenting Newborn must be covered for injury, sickness, or the cost of transporting the newborn to the nearest available facility that is appropriately stafffed. Coverage for transportation may not exceed the usual and customary charges, up to $1,000. Post partum assessment and newborn assessment must be performed.
Mental/Behavioral Health Outpatient Services
Covered
$30.00 100.00% Excludes services for psychological testing associated with the evaluation and diagnosis of learning disabilities or for mental retardation.
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$30.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$15.00 100.00% Certain off-label uses of cancer drugs will be covered in accordance with state law.
Preferred Brand Drugs
Covered
$30.00 100.00% Certain off-label uses of cancer drugs will be covered in accordance with state law.
Non-Preferred Brand Drugs
Covered
$60.00 100.00% Certain off-label uses of cancer drugs will be covered in accordance with state law.
Specialty Drugs
Covered
$250.00 100.00% Certain off-label uses of cancer drugs will be covered in accordance with state law.
Outpatient Rehabilitation Services
Covered
25.00% Coinsurance after deductible 100.00%35 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic.
Habilitation Services
Covered
25.00% Coinsurance after deductible 100.00% For outpatient habilitative and rehabilitative services for which there is no reasonable expectation of acquiring, restoring, improving or maintaining a level of function 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.
Chiropractic Care
Covered
25.00% Coinsurance after deductible 100.00%35 Visit(s) per Benefit Period The following are specifically excluded from chiropractic care and osteopathic services: Charges for care not provided in an office setting, Chelation therapy, Maintenance or preventive treatment consisting of routine, long-term, or not medically necessary care provided to prevent reoccurrences or to maintain the patient?s current status, Manipulation under anesthesia, Services of a chiropractor or osteopath that are not within their scope of practice, as defined by state law, Vitamin or supplement therapy. Combined limit for all outpatient therapy plus chiropractic. Includes Massage Therapy and Spinal Manipulation.
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 100.00%
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%
Routine Foot Care
Covered
25.00% Coinsurance after deductible 100.00%
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
25.00% Coinsurance after deductible 100.00%1 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
25.00% Coinsurance after deductible 100.00%1 Item(s) per Benefit Period
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$30.00 100.00%35 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 100.00%35 Visit(s) per Benefit Period If provided in an Inpatient setting, member must be able to actively participate in 2 rehabilitative therapies and be able to tolerate at least 3 hours per day of skilled Rehab services for at least 5 days a week. Member?s condition must be likely to significantly improve. Inpatient rehab limit is 21 days. Combined limit for all outpatient therapy plus chiropractic.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
25.00% Coinsurance after deductible 100.00%
Accidental Dental
Covered
25.00% Coinsurance after deductible 100.00%
Dialysis
Covered
25.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
25.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
25.00% Coinsurance after deductible 100.00%
Radiation
Covered
25.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
25.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
25.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
No Charge 100.00% Diabetes coverage includes ‘nutrition counseling’; home health services include ‘nutritional guidance.’
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 100.00% Only for Breast reconstruction following a Mastectomy.
Gender Affirming Care
Not Covered
Mammogram
Covered
No Charge 100.00% Coverage for at least the following: (a)Baseline mammogram for any woman who is 35 or older, but younger than 40. (b) Mammogram every 2 years for any woman who is 40 or older, but younger than 50 or more frequently based on the patient’s physician’s recommendation. (c) A mammogram every year for any woman who is 50 or older. (d) One or more mammograms a year, based on a physician’s recommendation for any woman who is at risk for breast cancer
Mastectomy
Covered
25.00% Coinsurance after deductible 100.00% Includes post-mastectomy care
Child Health Supervision
Covered
25.00% 100.00% Services must be covered from birth until age 16 and exempt from deductibles. Must receive periodic visits, appropriate immunizations, and laboratory tests.
Diabetes Care Management
Covered
25.00% Coinsurance after deductible 100.00%
Dental Anesthesia
Covered
25.00% Coinsurance after deductible 100.00%
Congenital Anomaly, including Cleft Lip/Palate
Covered
25.00% Coinsurance after deductible 100.00% Coverage must include medical, dental, speech therapy, audiology, and nutrition services but only if these services are prescribed by the treating physician or surgeon and the physician or surgeon certifies that the services are medically necessary and consequent to treating the cleft lip or cleft palate
Bone Marrow Transplant
Covered
25.00% Coinsurance after deductible 100.00%
Enteral Formulas
Covered
25.00% Coinsurance after deductible 100.00% Coverage required until the age of 25
Osteoporosis
Covered
25.00% Coinsurance after deductible 100.00%
Contraceptive Injections
Covered
25.00% Coinsurance after deductible 100.00%
Orthotic Devices
Covered
25.00% Coinsurance after deductible 100.00% Expenses for arch supports, shoe inserts designed to effect conformational changes in the foot or foot alignment, orthopedic shoes, over-the-counter, custom-made or built-up shoes, cast shoes, sneakers, readymade compression hose or support hose, or similar type devices/appliances regardless of intended use, except for therapeutic shoes (including inserts and/or modifications) for the treatment of severe diabetic foot disease; Expenses for orthotic appliances or devices, which straighten or re-shape the conformation of the head or bones of the skull or cranium through cranial banding or molding (e.g. dynamic orthotic cranioplasty or molding helmets); except when the orthotic appliance or device is used as an alternative to an internal fixation device as a result of surgery for craniosynostosis; and Expenses for devices necessary to exercise, train, or participate in sports

Free Preventive Services

There is no copayment or coinsurance for any of the following AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Table of Contents