Confident Care Gold 1 + Vision

64353OH0040001
Gold
HMO

Confident Care Gold 1 + Vision is a Gold HMO plan by Molina Healthcare.

IMPORTANT: You are viewing the 2023 version of Confident Care Gold 1 + Vision 64353OH0040001. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Confident Care Gold 1 + Vision is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Confident Care Gold 1 + Vision 64353OH0040001.
Insurer: Molina Healthcare
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 64353OH0040001

Cost-Sharing Overview

Confident Care Gold 1 + Vision 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 Confident Care Gold 1 + Vision?

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

Confident Care Gold 1 + Vision offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pain Management, 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 Confident Care Gold 1 + Vision 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

Confident Care Gold 1 + Vision 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
$20.00 100.00% Telephone consultations or consultations via electronic mail or internet/web site, except as required by law or as otherwise provided in plan document.
Specialist Visit
Covered
$50.00 100.00% Telephone consultations or consultations via electronic mail or internet/web site, except as required by law or as otherwise provided in plan document.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$20.00 100.00% Telephone consultations or consultations via electronic mail or internet/web site, except as required by law or as otherwise provided in plan document.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 100.00% Surgical treatment of dental conditions, reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dysfunction; surgeries or services for sexual transformation; surgical treatment of flat feet, subluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremity; treatment of telangiectatic dermal veins; cosmetic surgery; bariatric surgery. See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document; benefits for facility charges for Outpatient Services are payable for the removal of teeth or for other dental processes only if the patient?s medical condition or the dental procedure requires a Hospital setting to ensure the safety of the patient
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 100.00% Surgical treatment of dental conditions, reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dysfunction; surgeries or services for sexual transformation; surgical treatment of flat feet, subluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremity; treatment of telangiectatic dermal veins; cosmetic surgery; bariatric surgery. See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document.
Hospice Services
Covered
No Charge 100.00% Services provided by volunteers and housekeeping services. To be eligible for Hospice benefits, the patient must have a life expectancy of six months or less, as confirmed by the attending Physician.
Routine Dental Services (Adult)
Infertility Treatment
Covered
$50.00 100.00% Infertility and voluntary family planning services are required benefits under state law for HMO plans only per ORC section 1751.01 (A)(1)(h), and must be provided in accordance with Ohio Department of Insurance Bulletin No. 2009-07.
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Covered
No Charge 100.00%90 Visit(s) per Benefit Period Private Duty Nursing Services rendered in a Hospital or Skilled Nursing Facility. Private Duty Nursing Services are Covered Services only when provided through the Home Care Services benefit; Quantitative Limit has been determined as 90 – 110 visits per year and represents the number of visits to meet the established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply.
Routine Eye Exam (Adult)
Covered
No Charge 100.00%1 Exam(s) per Benefit Period
Urgent Care Centers or Facilities
Covered
$20.00 100.00%
Home Health Care Services
Covered
No Charge 100.00%100 Visit(s) per Benefit Period Provider; Services provided by a member of the patient?s immediate family; Services provided by volunteer ambulance associations for which patient is not obligated to pay; visiting teachers, vocational guidance and other counselors, and services related to outside occupational and social activities; Manipulation Therapy services rendered in the home. When therapy services are provided in the home (including physical, speech, and occupational therapy) as part of home health care services, they are not subject to separate visit limits for therapy services. The 100 visit/year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting.
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible For care received in an emergency room, which is not, Emergency Care, including, but not limited to suture removal in an emergency room.
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible Non Covered Services for Ambulance include but are not limited to, trips to: a Physician?s office or clinic; a morgue or funeral home; ambulance usage when another type of transportation can be used without endangering the member’s health or any ambulance usage for the convenience of the member, family, or physician; transport by ambulette. Ambulance Services are transportation by a vehicle (including ground, water, fixed wing and rotary wing air transportation) designed, equipped and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals: from home, scene of accident or medical emergency to a hospital; between hospitals; between a hospital and skilled nursing facility; or from a hospital or skilled nursing facility to home; ambulance trips must be made to the closest facility that can give covered services appropriate for the member’s condition.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 100.00% Surgical treatment of dental conditions, reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dysfunction; surgeries or services for sexual transformation; surgical treatment of flat feet, subluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremity; treatment of telangiectatic dermal veins; cosmetic surgery; bariatric surgery. There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services; and ancillary (related) services.
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 100.00% Surgical treatment of dental conditions, reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dysfunction; surgeries or services for sexual transformation; surgical treatment of flat feet, subluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremity; treatment of telangiectatic dermal veins; cosmetic surgery; bariatric surgery. There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient medical care visits limited to one visit per day by any one physician.
Bariatric Surgery
Bariatric surgery, regardless of the purpose it is proposed or performed. This includes Roux- en-Y(RNY), Laparoscopic gastric bypass surgery or other gastric bypass surgery (surgical procedures that reduce stomach capacity and divert partially digested food from the duodenum to the jejunum, the section of the small intestine extending from the duodenum), or Gastroplasty, (surgical procedures that decrease the size of the stomach), or gastric banding procedures. Complications directly related to bariatric surgery that results in an Inpatient stay or an extended inpatient stay for the bariatric surgery, are not covered. See Explanation column for details of when this exclusion DOES NOT apply.
Cosmetic Surgery
For any procedures, services, equipment or supplies provided in connection with cosmetic services. Cosmetic services are primarily intended to preserve, change or improve appearance or are furnished for psychiatric or psychological reasons. No benefits are available for surgery or treatments to change the texture or appearance of skin or to change the size, shape or appearance of facial or body features (such as nose, eyes, ears, cheeks, chin, chest or breasts). Complications directly related to cosmetic services treatment or surgeries are not covered. See Explanation column for details of when this exclusion DOES NOT apply.
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 100.00%90 Days per Benefit Period Custodial or domiciliary care. Benefits include Items and services provided as an inpatient in a skilled nursing bed of skilled nursing facility or hospital, including room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies.
Prenatal and Postnatal Care
Covered
No Charge 100.00% Any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple). Includes post-delivery follow-up care performed, by a physician or nurse, within 72 hours of discharge, through home health care visits or, at patient?s discretion, in a medical setting. This coverage includes, but is not limited to parent education; assistance and training in breast or bottle feeding; and routine maternal or neonatal tests and screening (including collection of sample for hereditary and metabolic newborn screening).
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 100.00% Any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple). Unless otherwise required under state or federal law, if Maternity Services are not covered for any reason, Hospital charges for ordinary routine nursery care for a well newborn are also not covered. Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Prenatal Care.
Mental/Behavioral Health Outpatient Services
Covered
$20.00 100.00% Custodial or domiciliary Care. Supervised living or halfway houses, services or care provided or billed by a hotel, health resort, convalescent/rest/nursing home, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps. Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00% Custodial or domiciliary Care. Room and board charges unless the treatment provided meets medical necessity criteria for Inpatient admission for patient’s condition. Supervised living or halfway houses, services or care provided or billed by a hotel, health resort, convalescent/rest/nursing home, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps. Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Substance Abuse Disorder Outpatient Services
Covered
$20.00 100.00% Services or care provided or billed by a halfway house, hotel, health resort, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps. Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00% Custodial or domiciliary Care. Room and board charges unless the treatment provided meets medical necessity criteria for Inpatient admission for patient’s condition. Supervised living or halfway houses, services or care provided or billed by a hotel, health resort, convalescent/rest/nursing home, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps. Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Generic Drugs
Covered
$15.00 100.00% Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications. Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state’s EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.
Preferred Brand Drugs
Covered
$50.00 100.00% Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications. Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state’s EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.
Non-Preferred Brand Drugs
Covered
30.00% Coinsurance after deductible 100.00% Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications. Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state’s EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.
Specialty Drugs
Covered
30.00% Coinsurance after deductible 100.00% Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications. Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of (1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the state’s EHB-benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive/Screening/Immunization benefits.
Outpatient Rehabilitation Services
Covered
$50.00 100.00%116 Visit(s) per Benefit Period Non-Covered Services include: Physical Therapy – maintenance therapy, repetitive exercise, range of motion and passive exercises that are not related to restoration of a specific loss of function; general exercise programs; diathermy, ultrasound and heat treatments for pulmonary conditions; diapulse; work hardening. Occupational Therapy – diversional, recreational, vocational therapies and supplies; general exercises to promote overall fitness and flexibility; therapy to improve motivation; suction therapy for newborns (feeding machines); soft tissue mobilization (visceral manipulation or visceral soft tissue manipulation), augmented soft tissue mobilization, myofascial; adaptions to the home. Cardiac Rehabilitation ? home programs, ongoing conditioning and maintenance. Pulmonary Rehabilitation ? services provided in the acute inpatient rehabilitation setting Therapy Services rendered in the home as part of Home Care Services will be subject to the Home Care Services visit limits; outpatient rehabilitation services visit limits will not apply. If different types of Therapy Services are performed during one Physician Home Visit, Office Service, or Outpatient Service, then each different type of Therapy Service performed will be considered a separate Therapy Visit. Each Therapy Visit will count against the applicable maximum visits per Benefit Period listed below: Physical, Occupational and Speech Therapy limited to 20 visits each. Cardiac Rehabilitation limited to 36 visits. Pulmonary Rehabilitation limited to 20 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply. Benefit also includes Physical Medicine and Rehabilitation Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services.
Habilitation Services
Covered
$50.00 100.00% Limits may apply to some services; includes benefits for health care services and devices that help a person keep, learn or improve skills and functioning for daily living, including treatment of Autism Spectrum Disorders to children (0 – 21), which at a minimum shall include: (1) Out-Patient Physical Rehabilitation Services including (a) Speech and Language therapy and/or Occupational therapy, 20 visits per year of each service; and (b) Clinical Therapeutic Intervention, which include but are not limited to Applied Behavioral Analysis, 20 hours per week; and (2) Mental/Behavioral Health Outpatient Services to provide consultation, assessment, development and oversight of treatment plans.
Chiropractic Care
Covered
$50.00 100.00%12 Visit(s) per Benefit Period Manipulation therapy services rendered in the home as part of Home Care Services. Benefit limit applies for Osteopathic/Chiropractic Manipulation Therapy.
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 100.00% Items for personal hygiene, environmental control or convenience; exercise equipment; repair and replacement due to misuse, malicious breakage or gross neglect, loss or theft; medical and surgical supplies (usually stocked in the home for general use like- band aids, thermometers, and petroleum jelly); arch supports; doughnut cushions; vitamins; medi-jectors; air conditioners; hot packs; ice bags/ cold pack pump; raised toilet seats; rental of equipment where facility is expected to provide such equipment; trans lift chairs; treadmill exerciser; tub chair; dentures, dental appliances; non-rigid appliances; artificial heart implants; wigs (except following cancer treatment); penile prosthesis in men suffering impotency; orthopedic shoes (except therapeutic shoes for diabetics); foot support devices and corrective shoes, unless they are an integral part of a leg brace; standard elastic stockings and other supplies not specially made and fitted (except as specified under medical supplies); garter belts or similar devices. Covered services include durable medical equipment, medical devices and supplies, prosthetics and appliances, including cochlear implants and eyeglasses/contact lenses (for cataract surgery or injury), and medical/surgical supplies and equipment that serve only a medical purpose for the management of disease. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period; (as required by the Women?s Health and Cancer Rights Act); Left Ventricular Artificial Devices (LVAD) covered only as bridge to heart transplant.
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00% Services with an ‘A’ or ‘B’ rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration including: women?s contraceptives, sterilization procedures, and counseling; breastfeeding support, supplies, and counseling (benefits for breast pumps are limited to one pump per benefit period); and gestational diabetes screening; routine screening mammograms; routine cytologic screening; child health supervision services from birth to age 9.
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Exam(s) per Year Coverage includes benefits specified in the FEDVIP FEP Blue Vision – High Option plan, including low vision benefits.
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year Coverage includes benefits specified in the FEDVIP FEP Blue Vision – High Option plan, including low vision benefits.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$50.00 100.00%20 Visit(s) per Benefit Period
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$50.00 100.00%40 Visit(s) per Benefit Period Non-Covered Services include: Physical Therapy – maintenance therapy, repetitive exercise, range of motion and passive exercises that are not related to restoration of a specific loss of function; general exercise programs; diathermy, ultrasound and heat treatments for pulmonary conditions; diapulse; work hardening. Occupational Therapy – diversional, recreational, vocational therapies and supplies; general exercises to promote overall fitness and flexibility; therapy to improve motivation; suction therapy for newborns (feeding machines); soft tissue mobilization (visceral manipulation or visceral soft tissue manipulation), augmented soft tissue mobilization, myofascial; adaptions to the home. Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
$15.00 100.00%
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
Adult dental treatment, regardless of origin or cause, is excluded except as specified in the base-benchmark plan when related to accidental injury (limits apply), or for certain services related to transplant preparation, initiation of immunosuppresives, or direct treatment of acute traumatic injury, cancer or cleft palate. Excluded dental treatment includes but is not limited to: Preventive care, diagnosis, treatment of or related to the teeth, jawbones (except that TMJ is a Covered Service) or gums.
Orthodontia – Adult
Adult dental treatment, regardless of origin or cause, is excluded except as specified in the base-benchmark plan when related to accidental injury (limits apply), or for certain services related to transplant preparation, initiation of immunosuppresives, or direct treatment of acute traumatic injury, cancer or cleft palate. Excluded dental treatment includes but is not limited to: Preventive care, diagnosis, treatment of or related to the teeth, jawbones (except that TMJ is a Covered Service) or gums.
Major Dental Care – Adult
Adult dental treatment, regardless of origin or cause, is excluded except as specified in the base-benchmark plan when related to accidental injury (limits apply), or for certain services related to transplant preparation, initiation of immunosuppresives, or direct treatment of acute traumatic injury, cancer or cleft palate. Excluded dental treatment includes but is not limited to: Preventive care, diagnosis, treatment of or related to the teeth, jawbones (except that TMJ is a Covered Service) or gums.
Abortion for Which Public Funding is Prohibited
Transplant
Covered
25.00% Coinsurance after deductible 100.00% Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined). Transplant benefits apply to any medically necessary human organ and stem cell/bone marrow transplants (except cornea and kidney transplants) and transfusions including necessary acquisition procedures, harvest and storage, necessary preparatory myeloablative therapy, and initial evaluation/testing to determine eligibility as a transplant candidate.
Accidental Dental
Covered
25.00% Coinsurance after deductible 100.00%3000 Dollars per Episode Damage to teeth due to chewing or biting is not deemed an accidental injury and is not covered. Quantitative Limit represents established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply. Coverage for dental services resulting from an accidental injury when treatment is performed within 12 months after the injury. The benefit limit will not apply to outpatient facility charges, anesthesia billed by a provider other than the physician performing the service, or to covered services required by law; coverage includes oral examinations, x-rays, tests and laboratory examinations, restorations, prosthetic services, oral surgery, mandibular/maxillary reconstruction, anesthesia and include facility charges for outpatient services for the removal of teeth or for other dental processes if the patient?s medical condition or the dental procedure requires a hospital setting to ensure the safety of the patient.
Dialysis
Covered
$50.00 100.00% Benefits include supportive use of an artificial kidney machine.
Allergy Testing
Covered
$20.00 100.00%
Chemotherapy
Covered
30.00% Coinsurance after deductible 100.00%
Radiation
Covered
25.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
No Charge 100.00% Diabetes Self-Management Training for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition.
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 100.00% Dentures, replacing teeth or structures directly supporting teeth; Dental appliances; Such non-rigid appliances as elastic stockings, garter belts, arch supports and corsets; Artificial heart implants; Wigs (except following cancer treatment); Penile prosthesis in men suffering impotency resulting from disease or injury. Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that 1) Replace all or part of a missing body part and its adjoining tissues; or 2) Replace all or part of the function of a permanently useless or malfunctioning body part.
Infusion Therapy
Covered
25.00% Coinsurance after deductible 100.00% Home IV therapy includes but is not limited to: injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy.
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 100.00% Benefits provided for temporomandibular (joint connecting the lower jaw to the temporal bone at the side of the head) and craniomandibular (head and neck muscle) disorders.
Nutritional Counseling
Covered
No Charge 100.00% Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services (includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors).
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 100.00% Reconstructive services needed as a result of an earlier treatment are covered only if the first treatment would have been a covered service under the plan; coverage for reconstructive services does not apply to orthognathic surgery. Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental 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

Free Preventive Services

There is no copayment or coinsurance for any of the following Confident Care Gold 1 + Vision 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 Confident Care Gold 1 + Vision 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 Confident Care Gold 1 + Vision?

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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