Aetna Gold OAEPO 1650 100% HSA T - 77422DC0110003 Health Insurance Plan
Aetna Life Insurance Company health insurance plan with the Plan ID 77422DC0110003. The plan is called Aetna Gold OAEPO 1650 100% HSA T.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.90% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.10% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 77422DC0110003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | District of Columbia | ||||||||||||||||||
| Health Insurance Issuer | Aetna Life Insurance Company | ||||||||||||||||||
| Health Insurance Plan Variant | 77422DC0110003-01 | ||||||||||||||||||
| Provider Network(s) | ['DCN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 24 Dec 2024 06:21 GMT |
Aetna Gold OAEPO 1650 100% HSA T Health Insurance Plan Variant 77422DC0110003-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Pregnancy, Weight Loss Programs, Diabetes, Heart Disease |
| First Tier Utilization | 100% |
| Formulary ID | DCF004 |
| HIOS Product ID | 77422DC011 |
| HSA/HRA Employer Contribution | No |
| Import Date | 2/12/2024 |
| HSA Eligible | Yes |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 81.90% |
| Issuer ID | 77422 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | DCN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Except for Emergencies |
| Plan Effective Date | 1/1/2024 |
| Plan ID (Standard Component ID with Variant) | 77422DC0110003-01 |
| Plan Marketing Name | Aetna Gold OAEPO 1650 100% HSA T |
| Plan Type | EPO |
| Plan Variant Marketing Name | Aetna Gold OAEPO 1650 100% HSA T |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $800 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,650 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $1,650 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,650 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | DCS001 |
| Source Name | SERFF |
| Plan ID | 77422DC0110003 |
| State Code | DC |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | per person not applicable | $6600 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,650 |
| TEHBDedOutofNetFamily | per person not applicable | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $9100 per person | $9100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Aetna Gold OAEPO 1650 100% HSA T Health Insurance Plan, 77422DC0110003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Aetna Gold OAEPO 1650 100% HSA T, 77422DC0110003 Health Insurance Plan, 77422DC0110003
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Does Aetna Gold OAEPO 1650 100% HSA T Health Insurance Plan, 77422DC0110003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (77422DC0110003) Health Insurance Plan, Variant (77422DC0110003-01) offer Disease Management Programs?
Does (77422DC0110003) Health Insurance Plan, Variant (77422DC0110003-01) have Out Of Country Coverage?
Does (77422DC0110003) Health Insurance Plan, Variant (77422DC0110003-01) have Out of Service Area Coverage?
Does (77422DC0110003) Health Insurance Plan, Variant (77422DC0110003-01) offer Disease Management Programs?
Does Aetna Gold OAEPO 1650 100% HSA T Health Insurance Plan, Variant (77422DC0110003-01) offer Disease Management Programs for Heart disease?
Does Aetna Gold OAEPO 1650 100% HSA T Health Insurance Plan, Variant (77422DC0110003-01) offer Disease Management Programs for Diabetes?
Does Aetna Gold OAEPO 1650 100% HSA T Health Insurance Plan, Variant (77422DC0110003-01) offer Disease Management Programs for Pregnancy?
Does Aetna Gold OAEPO 1650 100% HSA T Health Insurance Plan, Variant (77422DC0110003-01) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API