BCBSVT Gold Plan - 13627VT0340003 Health Insurance Plan
Blue Cross and Blue Shield of Vermont health insurance plan with the Plan ID 13627VT0340003. The plan is called BCBSVT Gold Plan.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.30% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.70% 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 80.71% (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 19.29% 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 | 13627VT0340003 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Vermont | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross and Blue Shield of Vermont | ||||||||||||||||||
| Health Insurance Plan Variant | 13627VT0340003-03 | ||||||||||||||||||
| Provider Network(s) | ['VTN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 13627VT0340003-01 |
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| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
BCBSVT Gold Plan Health Insurance Plan Variant 13627VT0340003-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.807092068 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Maximum Out of Pocket for Drug EHB Benefits, Combined In/Out Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Drug EHB Benefits, Combined In/Out Network, Individual | Not Applicable |
| 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 | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $200 per person | $400 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $200 |
| Drug EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Drug EHB Benefits, In Network (Tier 1), Individual | $1,500 |
| Maximum Out of Pocket for Drug EHB Benefits, In Network (Tier 2), Individual | $1500 per person | $3000 per group |
| Maximum Out of Pocket for Drug EHB Benefits, Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Drug EHB Benefits, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 99% |
| First Tier Utilization | 100% |
| Formulary ID | VTF003 |
| HIOS Product ID | 13627VT034 |
| 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 | 81.30% |
| Issuer ID | 13627 |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | No |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out | Not Applicable |
| 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 | 30.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $1400 per person | $2800 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,400 |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family | $5600 per person | $11200 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $5,600 |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | VTN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | All members traveling outside the U.S. have access to the BlueCard Worldwide program. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Members may use preferred providers nationally through the BlueCard network. |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 13627VT0340003-03 |
| Plan Marketing Name | BCBSVT Gold Plan |
| Plan Type | EPO |
| Plan Variant Marketing Name | BCBSVT Gold Plan |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,570 |
| SBC Scenario, Having a Baby, Copayment | $30 |
| SBC Scenario, Having a Baby, Deductible | $1,400 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,190 |
| SBC Scenario, Having Diabetes, Deductible | $910 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $390 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,150 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | VTS001 |
| Source Name | SERFF |
| Plan ID | 13627VT0340003 |
| State Code | VT |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of BCBSVT Gold Plan Health Insurance Plan, 13627VT0340003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about BCBSVT Gold Plan, 13627VT0340003 Health Insurance Plan, 13627VT0340003
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Does BCBSVT Gold Plan Health Insurance Plan, 13627VT0340003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (13627VT0340003) Health Insurance Plan, Variant (13627VT0340003-03) offer Disease Management Programs?
Does (13627VT0340003) Health Insurance Plan, Variant (13627VT0340003-03) have Out Of Country Coverage?
Does (13627VT0340003) Health Insurance Plan, Variant (13627VT0340003-03) have Out of Service Area Coverage?
Does (13627VT0340003) Health Insurance Plan, Variant (13627VT0340003-03) offer Disease Management Programs?
Does BCBSVT Gold Plan Health Insurance Plan, Variant (13627VT0340003-03) offer Disease Management Programs for Asthma?
Does BCBSVT Gold Plan Health Insurance Plan, Variant (13627VT0340003-03) offer Disease Management Programs for Heart disease?
Does BCBSVT Gold Plan Health Insurance Plan, Variant (13627VT0340003-03) offer Disease Management Programs for Depression?
Does BCBSVT Gold Plan Health Insurance Plan, Variant (13627VT0340003-03) offer Disease Management Programs for Diabetes?
Does BCBSVT Gold Plan Health Insurance Plan, Variant (13627VT0340003-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does BCBSVT Gold Plan Health Insurance Plan, Variant (13627VT0340003-03) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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