Avera $4000 - 60536SD0020043 Health Insurance Plan
Avera Health Plans, Inc. health insurance plan with the Plan ID 60536SD0020043. The plan is called Avera $4000.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.64% (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 28.36% 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 | 60536SD0020043 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | South Dakota | ||||||||||||||||||
| Health Insurance Issuer | Avera Health Plans, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 60536SD0020043-00 | ||||||||||||||||||
| Provider Network(s) | COMMERCIAL | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 60536SD0020043-00 Standard On Exchange Plan - 60536SD0020043-01 Open to Indians below 300% FPL - 60536SD0020043-02 Open to Indians above 300% FPL - 60536SD0020043-03 73% AV Silver Plan - 60536SD0020043-04 |
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| Last Plan Update Date | Tue, 13 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Avera $4000 Health Insurance Plan, 60536SD0020043-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Treatment must be completed within 12 months of the injury. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime Exclusions: Procedure(s) per Lifetime |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Limit: 1.0 Visit(s) per 6 Months Exclusions: Visit(s) per 6 Months |
YES | No Charge |
100.00% |
| Chemotherapy
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Chiropractic Care
|
YES | $40.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months Exclusions: Visit(s) per 6 Months |
YES | No Charge |
100.00% |
| Diabetes Education
Limit: 8.0 Visit(s) per Year Exclusions: Visit(s) per Year Quantity Limit: Two certified diabetes education programs per member per lifetime, and eight visits per benefit year for follow-up training once patient has participated in a diabetes education program. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Dialysis
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $700.00 |
$700.00 |
| Emergency Transportation/Ambulance
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: Item(s) per Year One frame from the designated pediatric eyewear collection are covered. |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered. |
YES | $20.00 |
100.00% |
| Habilitation Services
Cardiac and pulmonary rehab services from participating providers are coinsurance after deductible and have a 36-visit maximum per plan year. Preauthorization required for all Applied Behavioral Analysis services. |
YES | $40.00 |
60.00% Coinsurance after deductible |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Hospice Services
Limit: 185.0 Days per Year Exclusions: Days per Year Care (generally in a home setting) for patients who are terminally ill and who have a life expectancy of six months or less. Hospice respite care has a quantity limit of 15 inpatient days and 15 outpatient days per lifetime. Hospice respite care must be used in increments of not more than five days at a time. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
Major lab and X-ray services may include PET scan, MRI, CT scan, SPECT scan, cardiovascular, nuclear medicine and MRA. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Infusion therapy is covered when provided in the home (home infusion therapy). |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Frequency limitations may apply. |
YES | 50.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
Coinsurance will apply for services other than therapy performed in the office or any service at a facility. |
YES | $40.00 |
60.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered. |
YES | $130.00 |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Frequency limitations may apply. |
YES | 50.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $40.00 |
60.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Cardiac and pulmonary rehab services from participating providers are coinsurance after deductible and have a 36-visit maximum per plan year. Preauthorization required for all Applied Behavioral Analysis services. |
YES | $40.00 |
60.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Preferred Brand Drugs
Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered. |
YES | $40.00 |
100.00% |
| Prenatal and Postnatal Care
Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
Age and frequency limitations may apply |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $40.00 |
60.00% Coinsurance after deductible |
| Private-Duty Nursing
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Prosthetic Devices
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Radiation
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Reconstructive Surgery
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Cardiac and pulmonary rehab services from participating providers are coinsurance after deductible and have a 36-visit maximum per plan year. Preauthorization required for all Applied Behavioral Analysis services. |
YES | $40.00 |
60.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Cardiac and pulmonary rehab services from participating providers are coinsurance after deductible and have a 36-visit maximum per plan year. Preauthorization required for all Applied Behavioral Analysis services. |
YES | $40.00 |
60.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Exclusions: Visit(s) per Year One diagnostic exam per calendar year for children under the age of 19 from a VSP provider. |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 100.0 Days per Admission Exclusions: Days per Admission 100-day confinement limit is for services from participating providers. 60-day confinement limit for services from non-participating providers. Same confinement limit if readmitted with same diagnosis within 60 days. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $60.00 |
60.00% Coinsurance after deductible |
| Specialty Drugs
Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
Coinsurance will apply for services other than therapy performed in the office or any service at a facility. |
YES | $40.00 |
60.00% Coinsurance after deductible |
| Transplant
Transplants are subject to Case Management. |
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
In-network benefit for services outside of service area. When using Out-of-Network Provider inside service area you may contact the plan to determine if your visit qualifies for in-network benefits. |
YES | $40.00 |
60.00% Coinsurance after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Age and frequency limitations may apply. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 40.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
Avera $4000 Health Insurance Plan Variant 60536SD0020043-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.716420537702975 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | SDF003 |
| Formulary URL | URL |
| HIOS Product ID | 60536SD002 |
| Import Date | 2024-08-13 20:01:38 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 60536 |
| Issuer Marketplace Marketing Name | Avera Health Plans |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | SDN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency or urgent care services are covered if traveling outside of our service area. No coverage for health services if you travel outside our service area for the purpose of seeking medical treatment. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 60536SD0020043-00 |
| Plan Level Exclusions | Abortion (except when the life of the mother is endangered), acupuncture, cosmetic surgery, dental care for adults, hearing aids, infertility treatment, long-term care, non-emergency care when traveling outside the United States, routine eye care for adults, and weight loss programs. |
| Plan Marketing Name | Avera $4000 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Avera $4000 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,400 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $4,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,100 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,300 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | SDS003 |
| Source Name | SERFF |
| Plan ID | 60536SD0020043 |
| State Code | SD |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person 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 Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person 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 | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $8000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,000 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $20000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $10000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $10,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Avera $4000 Health Insurance Plan, 60536SD0020043
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Avera $4000, 60536SD0020043 Health Insurance Plan, 60536SD0020043
-
Does Avera $4000 Health Insurance Plan, 60536SD0020043 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (60536SD0020043) Health Insurance Plan, Variant (60536SD0020043-00) offer Disease Management Programs?
Does (60536SD0020043) Health Insurance Plan, Variant (60536SD0020043-00) have Out Of Country Coverage?
Does (60536SD0020043) Health Insurance Plan, Variant (60536SD0020043-00) have Out of Service Area Coverage?
Does (60536SD0020043) Health Insurance Plan, Variant (60536SD0020043-00) offer Disease Management Programs?
Does Avera $4000 Health Insurance Plan, Variant (60536SD0020043-00) offer Disease Management Programs for Asthma?
Does Avera $4000 Health Insurance Plan, Variant (60536SD0020043-00) offer Disease Management Programs for Heart disease?
Does Avera $4000 Health Insurance Plan, Variant (60536SD0020043-00) offer Disease Management Programs for Diabetes?
Does Avera $4000 Health Insurance Plan, Variant (60536SD0020043-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Avera $4000 Health Insurance Plan, Variant (60536SD0020043-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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