Aetna Life Insurance Company health insurance plan with the Plan ID 77422DC0110011. The plan is called Aetna Silver OAEPO 3200 100% HSA E.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.44% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.56% of the costs of all covered benefits (according to the Issuer).
Health Insurance Plan ID | 77422DC0110011 | ||||||||||||||||||
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Health Insurance Plan Year | 2024 | ||||||||||||||||||
State | District of Columbia | ||||||||||||||||||
Health Insurance Issuer | Aetna Life Insurance Company | ||||||||||||||||||
Health Insurance Plan Variant | 77422DC0110011-01 | ||||||||||||||||||
Provider Network(s) | ['DCN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 17 Dec 2024 06:12 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, 17 Dec 2024 06:12 GMT |
Plan Attribute | Value |
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Business Year | 2024 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Silver On Exchange Plan |
Dental Only Plan | No |
Disease Management Programs Offered | Pregnancy, Weight Loss Programs, Diabetes, Heart Disease |
First Tier Utilization | 100% |
Formulary ID | DCF009 |
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 | 71.44% |
Issuer ID | 77422 |
Market Coverage | SHOP (Small Group) |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Silver |
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) | 77422DC0110011-01 |
Plan Marketing Name | Aetna Silver OAEPO 3200 100% HSA E |
Plan Type | EPO |
Plan Variant Marketing Name | Aetna Silver OAEPO 3200 100% HSA E |
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 | $3,200 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $600 |
SBC Scenario, Having Diabetes, Deductible | $3,200 |
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 | $2,800 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | DCS001 |
Source Name | SERFF |
Plan ID | 77422DC0110011 |
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 | $3200 per person | $6400 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,200 |
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 | $7500 per person | $15000 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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 17 Dec 2024 06:12 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