Anthem EPO 25/0%/8700 Gold INN Blue Access Dep 25 Wellness Pediatric Dental DP C Opt Out RE A Opt Out - 44113NY0370108 Health Insurance Plan
Empire HealthChoice Assurance, Inc. health insurance plan with the Plan ID 44113NY0370108. The plan is called Anthem EPO 25/0%/8700 Gold INN Blue Access Dep 25 Wellness Pediatric Dental DP C Opt Out RE A Opt Out.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.70% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.30% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 82.16% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 17.84% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 44113NY0370108 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | Empire HealthChoice Assurance, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 44113NY0370108-01 | ||||||||||||||||||
| Provider Network(s) | ['NYN004'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 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, 10 Dec 2024 06:32 GMT |
Anthem EPO 25/0%/8700 Gold INN Blue Access Dep 25 Wellness Pediatric Dental DP C Opt Out RE A Opt Out Health Insurance Plan Variant 44113NY0370108-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.821621175 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $150 per person | $300 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $150 |
| Drug EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Disease Management Programs Offered | Pregnancy, Depression, Diabetes, Heart Disease, Asthma |
| First Tier Utilization | 100% |
| Formulary ID | NYF011 |
| HIOS Product ID | 44113NY037 |
| HSA/HRA Employer Contribution | No |
| Import Date | 2/12/2024 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 81.70% |
| Issuer ID | 44113 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | NYN004 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Urgent/Emergency Coverage Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Standard Bluecard PPO Network |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 44113NY0370108-01 |
| Plan Marketing Name | Anthem EPO 25/0%/8700 Gold INN Blue Access Dep 25 Wellness Pediatric Dental DP C Opt Out RE A Opt Out |
| Plan Type | EPO |
| Plan Variant Marketing Name | Anthem EPO 25/0%/8700 Gold INN Blue Access Dep 25 Wellness Pediatric Dental DP C Opt Out RE A Opt Out |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $700 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,400 |
| SBC Scenario, Having Diabetes, Deductible | $150 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,700 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NYS002 |
| Source Name | SERFF |
| Plan ID | 44113NY0370108 |
| State Code | NY |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $8700 per person | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| 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 | No |
Copay & Coinsurance of Anthem EPO 25/0%/8700 Gold INN Blue Access Dep 25 Wellness Pediatric Dental DP C Opt Out RE A Opt Out Health Insurance Plan, 44113NY0370108
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Anthem EPO 25/0%/8700 Gold INN Blue Access Dep 25 Wellness Pediatric Dental DP C Opt Out RE A Opt Out, 44113NY0370108 Health Insurance Plan, 44113NY0370108
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Does Anthem EPO 25/0%/8700 Gold INN Blue Access Dep 25 Wellness Pediatric Dental DP C Opt Out RE A Opt Out Health Insurance Plan, 44113NY0370108 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (44113NY0370108) Health Insurance Plan, Variant (44113NY0370108-01) offer Disease Management Programs?
Does (44113NY0370108) Health Insurance Plan, Variant (44113NY0370108-01) have Out Of Country Coverage?
Does (44113NY0370108) Health Insurance Plan, Variant (44113NY0370108-01) have Out of Service Area Coverage?
Does (44113NY0370108) Health Insurance Plan, Variant (44113NY0370108-01) offer Disease Management Programs?
Does Anthem EPO 25/0%/8700 Gold INN Blue Access Dep 25 Wellness Pediatric Dental DP C Opt Out RE A Opt Out Health Insurance Plan, Variant (44113NY0370108-01) offer Disease Management Programs for Asthma?
Does Anthem EPO 25/0%/8700 Gold INN Blue Access Dep 25 Wellness Pediatric Dental DP C Opt Out RE A Opt Out Health Insurance Plan, Variant (44113NY0370108-01) offer Disease Management Programs for Heart disease?
Does Anthem EPO 25/0%/8700 Gold INN Blue Access Dep 25 Wellness Pediatric Dental DP C Opt Out RE A Opt Out Health Insurance Plan, Variant (44113NY0370108-01) offer Disease Management Programs for Depression?
Does Anthem EPO 25/0%/8700 Gold INN Blue Access Dep 25 Wellness Pediatric Dental DP C Opt Out RE A Opt Out Health Insurance Plan, Variant (44113NY0370108-01) offer Disease Management Programs for Diabetes?
Does Anthem EPO 25/0%/8700 Gold INN Blue Access Dep 25 Wellness Pediatric Dental DP C Opt Out RE A Opt Out Health Insurance Plan, Variant (44113NY0370108-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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