AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards
72760DE0010004
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 72760DE0010004. 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.
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Plan Overview
This is a plan overview for 2023 version of AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards 72760DE0010004.
| Insurer: | AmeriHealth Caritas Next |
| Network Type: | HMO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 72760DE0010004 |
Cost-Sharing Overview
AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8,700.00 | $8700 per person | $17400 per group |
| Deductible: | $2,000.00 | $2000 per person | $4000 per group |
| Coinsurance: | 25.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | Not Applicable | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $2,000.00 |
| Copayment: | $70.00 |
| Coinsurance: | $2,600.00 |
| Limit: | $0.00 |
| Deductible: | $900.00 |
| Copayment: | $900.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
| Deductible: | $2,000.00 |
| Copayment: | $300.00 |
| Coinsurance: | $20.00 |
| Limit: | $0.00 |
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% | Private duty nursing; respite care; care not prescribed in the approved treatment plan; financial, legal, or estate planning, and; hospice care in an acute care facility, except when a patient in hospice care requires services in an inpatient setting for a limited time |
| Routine Dental Services (Adult) | |||
| Infertility Treatment Covered | 25.00% Coinsurance after deductible | 100.00% | 6 Procedure(s) per Lifetime For IVF services, retrievals must be completed before the individual is 45 years old and transfers must be completed before the individual is 50 years old. The benefit is limited to six (6) completed egg retrievals per lifetime, with unlimited embryo transfers in accordance with the guidelines of the American Society for Reproductive Medicine, using single embryo transfer (SET) when recommended and medically appropriate. We will cover services for the diagnosis, treatment, and correction of any underlying causes of infertility when determined to be medically necessary by a network provider. This includes coverage of certain prescription drugs, in vitro fertilization (IVF), Gamete Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer (ZIFT), and standard fertility preservation services for covered persons who must undergo medically necessary treatment that may cause iatrogenic infertility. |
| Long-Term/Custodial Nursing Home Care | |||
| Private-Duty Nursing Covered | 25.00% Coinsurance after deductible | 100.00% | 240 Hours per Benefit Period This care isn’t covered when done in special care units of the hospital, such as: self-care units; selective care units; intensive care units. Covered health services under this section include medically necessary nursing care provided to a patient one on one by licensed nurses in an inpatient or home setting. Private duty nursing care is covered when you are an inpatient in an acute hospital. This care isn’t covered when done in special care units of the hospital such as: -self-care units -selective care units -intensive care units Inpatient private duty nursing care is not covered when done as a convenience even if authorized by your doctor. |
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $45.00 | 100.00% | |
| Home Health Care Services Covered | 25.00% Coinsurance after deductible | 100.00% | 100 Visit(s) per Benefit Period Chronic condition care is not covered; drugs; lab tests; imaging services; inhalation therapy; chemotherapy and radiation therapy; dietary care; durable medical equipment; disposable supplies; care not prescribed in the approved treatment plan; volunteer care. We will cover certain services received in the home from a certified/licensed home health agency when ordered by a physician. Examples of these services include skilled care, physical/ occupational/speech and language/respiratory therapy, social work services, and home infusion. Services must only be provided on a part-time, intermittent basis and cannot be solely for assisting with activities of daily living. There’s a limit of one visit per day per specialty. (A nurse and home health aide count as one specialty for this benefit.) |
| 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 | We cover ambulance services (including voluntary services) by ground, air, or water in the event of an emergency. Services must be provided by a licensed ambulance, including volunteer, service provider and must take you to the nearest hospital where emergency care can be provided. Air Ambulance is covered only when no other means of travel is appropriate. We also cover nonemergency ambulance transportation by a licensed ambulance service (either ground, air, or water ambulance) when the transport is: ? From an acute facility to a subacute facility/setting. ? From an out-of-network hospital/facility to an in-network hospital/facility. ? To a hospital that provides a higher level of care than was available at the original hospital/facility. ? To a more cost-effective acute care facility. |
| 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 Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Cosmetic Surgery | |||
| Skilled Nursing Facility Covered | 25.00% Coinsurance after deductible | 100.00% | 120 Days per Admission Covered health services do not include custodial, domiciliary care, or long-term care admissions. The skilled nursing facility is a Network Provider. Coverage is limited to 120 days per confinement. A confinement includes all admissions not separated by 180 days. |
| 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% | |
| Mental/Behavioral Health Outpatient Services Covered | $30.00 | 100.00% | Exclusions include certain mental health and substance abuse services, including: aptitude tests, testing and treatment for learning disabilities, treatment for personality disorders, treatment [of] factitious disorders, treatment of sleep disorders, treatment of sexual and gender identity disorders, care beyond that needed to determine mental deficiency or retardation, marital/relationship counseling, and care at behavioral health facilities. Psychological tests (limit of 8 hours of tests per year). |
| Mental/Behavioral Health Inpatient Services Covered | 25.00% Coinsurance after deductible | 100.00% | Exclusions include certain mental health and substance abuse services, including: aptitude tests, testing and treatment for learning disabilities, treatment for personality disorders, treatment [of] factitious disorders, treatment of sleep disorders, treatment of sexual and gender identity disorders, care beyond that needed to determine mental deficiency or retardation, marital/relationship counseling, and care at behavioral health facilities. Methadone is not Covered |
| 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% | |
| Preferred Brand Drugs Covered | $30.00 | 100.00% | |
| Non-Preferred Brand Drugs Covered | $60.00 | 100.00% | |
| Specialty Drugs Covered | $100.00 | 100.00% | |
| Outpatient Rehabilitation Services Covered | 25.00% Coinsurance after deductible | 100.00% | 30 Visit(s) per Benefit Period OT and PT covered only when needed to help your condition improve in a reasonable and predictable time. Combined limit of 30 visits per benefit period for Rehabilitative Physical Therapy and Occupational Therapy; 30 visits per benefit period for Rehabilitative Speech Therapy. |
| Habilitation Services Covered | 25.00% Coinsurance after deductible | 100.00% | 30 Visit(s) per Benefit Period Speech therapy is not covered for attention disorders, behavior problems, conceptual handicaps, learning disabilities, developmental delays. Combined limit of 30 visits per benefit period for Habilitative Physical Therapy and Occupational Therapy; 30 visits per benefit period for Habilitative Speech Therapy. Applied Behavior analysis for autism spectrum disorder is also covered,. |
| Chiropractic Care Covered | 25.00% Coinsurance after deductible | 100.00% | The following limits apply: three modalities per visit, one visit per day. |
| Durable Medical Equipment Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Hearing Aids Covered | 25.00% Coinsurance after deductible | 100.00% | 1 Item(s) per 3 Years Benefits are limited to one wearable hearing aid per ear every three (3) years |
| Imaging (CT/PET Scans, MRIs) Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Preventive Care/Screening/Immunization Covered | No Charge | 100.00% | Colorectal cancer screening must be covered. |
| 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% | 30 Visit(s) per Benefit Period Speech therapy is not covered for attention disorders, behavior problems, conceptual handicaps, learning disabilities, developmental delays. Combined Rehabilitative and Habilitative limit of 30 visits per benefit period. Must be needed to improve speech problems caused by disease, trauma, congenital defect, or recent surgery. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $30.00 | 100.00% | 30 Visit(s) per Benefit Period OT and PT covered only when needed to help your condition improve in a reasonable and predictable time. Combined limit of 30 visits per benefit period for Rehabilitative Physical Therapy and Occupational Therapy. Must be needed to help your condition improve in a reasonable and predictable time, or needed to establish an effective home exercise program. |
| 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 Not Covered | Elective abortions Plan covers non-elective abortions necessary to avert the death of the member or to terminate pregnancies caused by rape or incest | ||
| Transplant Covered | 25.00% Coinsurance after deductible | 100.00% | Your health benefit plan has a maximum benefit limit per transplant of $10,000 for each cadaveric organ and up to $45,000 for each organ procured from a living donor including organ harvesting. Kidney and bone marrow transplants do not apply to this limit. For kidney transplants, if there is not a network transplant facility available living donor costs are limited to $50,000 not including harvesting. |
| 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% | Radiation therapy is covered for cancer and neoplastic diseases. |
| Diabetes Education | |||
| 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% | Treatment is covered if there is documented organic joint disease, or joint damage resulting from physical trauma |
| Nutritional Counseling Covered | No Charge | 100.00% | Also covered per USPSTF guidelines. |
| Reconstructive Surgery Covered | 25.00% Coinsurance after deductible | 100.00% | Only for breast reconstruction. |
| Gender Affirming Care Not Covered | |||
| Newborn Hearing Screening Covered | No Charge | 100.00% | |
| Cancer Monitoring Test Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Clinical Trials Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Diabetes Care Management Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Inherited Metabolic Disorder – PKU Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Reversible Contraceptives Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Autism Spectrum Disorders Covered | 25.00% Coinsurance after deductible | 100.00% | |
| School Based Health Centers Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Dental Services for Children with Severe Disabilities Covered | 25.00% Coinsurance after deductible | 100.00% |
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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
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