Gold 1 with Adult Vision Services

32355IL0020001
Gold
HMO

Gold 1 with Adult Vision Services is a Gold HMO plan by Molina Healthcare.

IMPORTANT: You are viewing the 2024 version of Gold 1 with Adult Vision Services 32355IL0020001. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Gold 1 with Adult Vision Services is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Gold 1 with Adult Vision Services 32355IL0020001.
Insurer: Molina Healthcare
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 32355IL0020001

Cost-Sharing Overview

Gold 1 with Adult Vision Services 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 Gold 1 with Adult Vision Services?

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

Gold 1 with Adult Vision Services offers the following features and referral requirements.

Wellness Program: Yes
Disease Program:
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 Gold 1 with Adult Vision Services 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

Gold 1 with Adult Vision Services 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 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$50.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
No Charge Not ApplicableNot Applicable 100.00%
Routine Dental Services (Adult)
Infertility Treatment
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Limitations vary based on procedures.
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Covered
No Charge Not ApplicableNot Applicable 100.00%
Routine Eye Exam (Adult)
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Benefit Period
Urgent Care Centers or Facilities
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
No Charge Not ApplicableNot Applicable 100.00%100.0 Visit(s) per Year
Emergency Room Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Cosmetic Surgery
Not Covered
Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered.
Skilled Nursing Facility
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Prenatal and Postnatal Care
Covered
No Charge Not ApplicableNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$15.00 Not ApplicableNot Applicable 100.00%
Preferred Brand Drugs
Covered
$50.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Non-Preferred Brand Drugs
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Specialty Drugs
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Rehabilitation Services
Covered
$20.00 Not ApplicableNot Applicable 100.00% Maintenance therapies not covered.
Habilitation Services
Covered
$20.00 Not ApplicableNot Applicable 100.00% Treatment must be medically necessary and therapeutic and not investigational.
Chiropractic Care
Covered
$20.00 Not ApplicableNot Applicable 100.00%25.0 Visit(s) per Benefit Period
Durable Medical Equipment
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%2.0 Visit(s) per 3 Years Benefits are for bone anchored hearing aids. Quantity limit applies to hearing aids for children.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Benefit provided for outpatient services and when these services are related to surgery or medical care.
Preventive Care/Screening/Immunization
Covered
No Charge Not ApplicableNot Applicable 100.00%
Routine Foot Care
Not Covered
Only covered for persons diagnosed with diabetes.
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Item(s) per Benefit Period
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$20.00 Not ApplicableNot Applicable 100.00% When rendered for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome) attention disorder, conceptual handicap or mental retardation, except as may be provided under this Certificate for Autism Spectrum Disorder(s).
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$20.00 Not ApplicableNot Applicable 100.00% Maintenance Speech Therapy is not covered.
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
$15.00 Not ApplicableNot Applicable 100.00% Benefit provided for outpatient services and when these services are related to surgery or medical care.
X-rays and Diagnostic Imaging
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Benefit provided for outpatient services and when these services are related to surgery or medical care.
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Limitations vary based on procedures.
Major Dental Care – Child
Not Covered
Limitations vary based on procedures.
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Transplant
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Facility fee may apply
Accidental Dental
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
$50.00 Not ApplicableNot Applicable 100.00%
Allergy Testing
Covered
$20.00 Not ApplicableNot Applicable 100.00% Cost Share may vary based on place of service.
Chemotherapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
No Charge Not ApplicableNot Applicable 100.00% Services must be rendered by a physician, or duly certified, or licensed health care professional with expertise in diabetes management.
Prosthetic Devices
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Cost Share may vary based on place of service.
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Covered
No Charge Not ApplicableNot Applicable 100.00%
Reconstructive Surgery
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Only includes benefits for mastectomy-related services.
Gender Affirming Care

Free Preventive Services

There is no copayment or coinsurance for any of the following Gold 1 with Adult Vision Services 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 Gold 1 with Adult Vision Services 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 Gold 1 with Adult Vision Services?

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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