CareSource Marketplace Federal Standard Gold

60224GA0020011
Gold
HMO

CareSource Marketplace Federal Standard Gold is a Gold HMO plan by CareSource.

IMPORTANT: You are viewing the 2023 version of CareSource Marketplace Federal Standard Gold 60224GA0020011. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

CareSource Marketplace Federal Standard Gold is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of CareSource Marketplace Federal Standard Gold 60224GA0020011.
Insurer: CareSource
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 60224GA0020011

Cost-Sharing Overview

CareSource Marketplace Federal Standard Gold 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 CareSource Marketplace Federal Standard Gold?

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

CareSource Marketplace Federal Standard Gold offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: Yes
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 CareSource Marketplace Federal Standard Gold covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency Services Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency Services Only
National Network: No

Additional Benefits and Cost-Sharing

CareSource Marketplace Federal Standard Gold 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)
Covered
$0.00 100.00%2 Visit(s) per Year $1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits.
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Covered
$50.00 100.00%1 Exam(s) per Year
Urgent Care Centers or Facilities
Covered
$45.00 $45.00
Home Health Care Services
Covered
25.00% Coinsurance after deductible 100.00%120 Visit(s) per Year A visit equals at least 2 hours
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible Emergency room copay or coinsurance is waived if you are admitted to the hospital directly from the Emergency Department.
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible Ambulance transports must be made to the closest local facility that can provide you with covered services appropriate for your medical condition.
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
Not Covered
Cosmetic Surgery
Covered
25.00% Coinsurance after deductible 100.00% Cosmetic Procedures do not include coverage for procedures or services that change or improve appearance without significantly improving physiological function, other than those mandated by State or Federal law.
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 100.00%60 Days per Year
Prenatal and Postnatal Care
Covered
$60.00 100.00%
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%
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%
Preferred Brand Drugs
Covered
$30.00 100.00%
Non-Preferred Brand Drugs
Covered
$60.00 100.00%
Specialty Drugs
Covered
$250.00 100.00%
Outpatient Rehabilitation Services
Covered
25.00% Coinsurance after deductible 100.00%40 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Manipulation Therapy, and Cognitive Rehabilitation therapy are limited to a combined 40 visits per year
Habilitation Services
Covered
$30.00 100.00%40 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, and Spinal Manipulations are limited to a combined 40 visits per Benefit Year
Chiropractic Care
Not Covered
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
0.00% 100.00% The recommendations by the USPSTF for breast cancer screenings, mammography and preventions issued prior to November 2009 will be considered current. Immunizations covered are those recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC).
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Covered
25.00% Coinsurance after deductible 100.00%4 Visit(s) per Year Nutritional counseling for the treatment of obesity, which includes morbid obesity.
Routine Eye Exam for Children
Covered
$0.00 0.00% 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
$0.00 0.00% 100.00%1 Item(s) per Year Limited to one pair of glasses or contact lenses per benefit year.
Dental Check-Up for Children
Covered
$0.00 100.00%2 Procedure(s) per Year See plan documents for details on benefit limits
Rehabilitative Speech Therapy
Covered
$30.00 100.00%40 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Manipulation Therapy, and Cognitive Rehabilitation therapy are limited to a combined 40 visits per year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 100.00%40 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Manipulation Therapy, and Cognitive Rehabilitation therapy are limited to a combined 40 visits per year
Well Baby Visits and Care
Covered
0.00% 100.00% Care provided for birth through age 5.
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
Covered
15.00% Coinsurance after deductible 100.00% See plan documents for details on benefit limits
Orthodontia – Child
Covered
40.00% Coinsurance after deductible 100.00% Limited to Medically Necessary Orthodontia. See plan documents for details on benefit limits.
Major Dental Care – Child
Covered
40.00% Coinsurance after deductible 100.00% See plan documents for details on benefit limits
Basic Dental Care – Adult
Covered
15.00% 100.00% $1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits.
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Covered
40.00% 100.00% $1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits.
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
25.00% Coinsurance after deductible 100.00%10000 Dollars per Procedure Limited to a combined maximum of $10,000 per covered organ transplant.
Accidental Dental
Covered
25.00% Coinsurance after deductible 100.00% Injury as a result of chewing or biting is not considered an accidental injury.
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% Insulin infusion devices.
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
25.00% Coinsurance after deductible 100.00%4 Visit(s) per Year
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 100.00% Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy.
Gender Affirming Care
Covered
25.00% Coinsurance after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following CareSource Marketplace Federal Standard Gold 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 CareSource Marketplace Federal Standard Gold 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 CareSource Marketplace Federal Standard Gold?

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

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