Standard Gold 2000

14624MS0010007
Gold
POS

Standard Gold 2000 is a Gold POS plan by Vantage Health Plan of Mississippi.

IMPORTANT: You are viewing the 2023 version of Standard Gold 2000 14624MS0010007. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Standard Gold 2000 is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Standard Gold 2000 14624MS0010007.
Insurer: Vantage Health Plan of Mississippi
Network Type: POS
Metal Type: Gold
HSA Eligible?: No
Plan ID: 14624MS0010007

Cost-Sharing Overview

Standard Gold 2000 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 Standard Gold 2000?

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

Standard Gold 2000 offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, 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 Standard Gold 2000 covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Limited to Emergency Services only. Covered as in-network.
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Out-of-Network Deductible and Co-insurance
National Network: No

Additional Benefits and Cost-Sharing

Standard Gold 2000 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 50.00% Coinsurance after deductible Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization.
Specialist Visit
Covered
$60.00 50.00% Coinsurance after deductible Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 50.00% Coinsurance after deductible Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Hospice Services
Covered
25.00% Coinsurance after deductible 100.00%6 Months per Lifetime Subject to Care Management.
Routine Dental Services (Adult)
Covered
No Charge No Charge2 Visit(s) per Year Covers exam and cleaning
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Covered
$60.00 50.00% Coinsurance after deductible1 Visit(s) per Year An added benefit
Urgent Care Centers or Facilities
Covered
$45.00 50.00% Coinsurance after deductible
Home Health Care Services
Covered
25.00% Coinsurance after deductible 100.00% Home Health Care services provided to a Member in lieu of an Inpatient Hospital Admission are covered; must obtain authorization.
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible The ER Coinsurance is waived if the visit results in an inpatient admission.
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Air ambulance services are covered in only specified situations.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible30 Days per Benefit Period Three-day prior inpatient stay
Prenatal and Postnatal Care
Covered
$30.00 50.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Minimum stay of 48 hours
Mental/Behavioral Health Outpatient Services
Covered
$30.00 50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Inpatient treatment for mental/behavioral health disorders must be Authorized
Substance Abuse Disorder Outpatient Services
Covered
$30.00 50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Inpatient treatment for substance abuse must be Authorized
Generic Drugs
Covered
$15.00 100.00% Quantity limits, authorizations and step therapy limits may apply.
Preferred Brand Drugs
Covered
$30.00 100.00% Quantity limits, authorizations and step therapy limits may apply.
Non-Preferred Brand Drugs
Covered
$60.00 100.00% Quantity limits, authorizations and step therapy limits may apply.
Specialty Drugs
Covered
$250.00 100.00% Specialty drugs may be limited to a thirty (30) day supply. Quantity limits, authorizations and step therapy limits may apply.
Outpatient Rehabilitation Services
Covered
$30.00 50.00% Coinsurance after deductible36 Visit(s) per Year Benefits available for outpatient cardiac rehabilitation.
Habilitation Services
Covered
$30.00 50.00% Coinsurance after deductible 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
$60.00 50.00% Coinsurance after deductible20 Visit(s) per Year Must be medically necessary. A treatment plan outlining goals of therapy, mode of therapy and duration of therapy must be submitted to Company by the provider prior to the initiation of treatment. The 20 visit limit is combined for chiropractic services, occupational therapy, and physical therapy.
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Various limitations apply
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
Covered
0.00% 50.00% Covered services must be included in Grade A and B Recommendations of the USPSTF and include all other preventive health services required by PPACA.
Routine Foot Care
Covered
No Charge 50.00%1 Visit(s) per Year Requires a Diabetes diagnosis.
Acupuncture
Not Covered
Weight Loss Programs
Covered
No Charge 100.00% Non-Vantage Weight Loss programs are excluded. Vantage Weight Loss programs are covered as part of the Vantage Wellness Program.
Routine Eye Exam for Children
Covered
$60.00 50.00% Coinsurance after deductible1 Visit(s) per Year
Eye Glasses for Children
Covered
50.00% 50.00% Coinsurance after deductible1 Item(s) per Benefit Period
Dental Check-Up for Children
Covered
No Charge No Charge2 Visit(s) per Year
Rehabilitative Speech Therapy
Covered
$30.00 50.00% Coinsurance after deductible20 Visit(s) per Year Not covered for learning disabilities and development problems.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 50.00% Coinsurance after deductible20 Visit(s) per Year The 20 visit limit is combined for chiropractic services, occupational therapy, and physical therapy.
Well Baby Visits and Care
Covered
0.00% 50.00%
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Lab services in the Emergency Room are subject to the deductible, if applicable.
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Basic Dental Care – Child
Covered
50.00% 50.00%
Orthodontia – Child
Covered
50.00% 50.00% Medically Necessary orthodontia only.
Major Dental Care – Child
Covered
50.00% 50.00%
Basic Dental Care – Adult
Covered
No Charge No Charge An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care.
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Covered
No Charge No Charge An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care.
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
25.00% Coinsurance after deductible 100.00% Non-EHB and out-of-network transplant services not covered
Accidental Dental
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Dialysis
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Allergy Testing
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Chemotherapy
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Radiation
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Must be medically necessary. Company may require a treatment plan, outlining the goals of therapy, mode of therapy, and duration of therapy, to be submitted by the provider prior to the initiation of treatment.
Diabetes Education
Covered
$30.00 50.00% Coinsurance after deductible
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Various limitations apply as stated in the Benchmark plan.
Infusion Therapy
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Medical necessity documentation and a treatment plan must be submitted to and approved by the Company prior to the commencement of treatment. Prior authorization is required.
Nutritional Counseling
Covered
$30.00 50.00% Coinsurance after deductible4 Visit(s) per Year Coverage only for diabetes education.
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 50.00% Coinsurance after deductible Plan only outlines benefits for breast reconstruction. Must be medically necessary and related to mastectomy.
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following Standard Gold 2000 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 Standard Gold 2000 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 Standard Gold 2000?

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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