BCBSVT Vermont Select Gold CDHP Plan - 13627VT0390001 Health Insurance Plan
Blue Cross and Blue Shield of Vermont health insurance plan with the Plan ID 13627VT0390001. The plan is called BCBSVT Vermont Select Gold CDHP Plan.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.93% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.07% 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 80.80% (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 19.20% 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 | 13627VT0390001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Vermont | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross and Blue Shield of Vermont | ||||||||||||||||||
| Health Insurance Plan Variant | 13627VT0390001-03 | ||||||||||||||||||
| 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). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard On Exchange Plan - 13627VT0390001-01 |
||||||||||||||||||
| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
BCBSVT Vermont Select Gold CDHP Plan Health Insurance Plan Variant 13627VT0390001-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.807974443 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| 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 | VTF012 |
| HIOS Product ID | 13627VT039 |
| 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 | 81.93% |
| Issuer ID | 13627 |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| 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) | 13627VT0390001-03 |
| Plan Marketing Name | BCBSVT Vermont Select Gold CDHP Plan |
| Plan Type | EPO |
| Plan Variant Marketing Name | BCBSVT Vermont Select Gold CDHP Plan |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $2,850 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $2,850 |
| 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 | $2,640 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | VTS001 |
| Source Name | SERFF |
| Plan ID | 13627VT0390001 |
| State Code | VT |
| 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 | $2850 per person | $5700 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,850 |
| 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 | $5700 per person | $5700 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $2,850 |
| 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 BCBSVT Vermont Select Gold CDHP Plan Health Insurance Plan, 13627VT0390001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about BCBSVT Vermont Select Gold CDHP Plan, 13627VT0390001 Health Insurance Plan, 13627VT0390001
-
Does BCBSVT Vermont Select Gold CDHP Plan Health Insurance Plan, 13627VT0390001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (13627VT0390001) Health Insurance Plan, Variant (13627VT0390001-03) offer Disease Management Programs?
Does (13627VT0390001) Health Insurance Plan, Variant (13627VT0390001-03) have Out Of Country Coverage?
Does (13627VT0390001) Health Insurance Plan, Variant (13627VT0390001-03) have Out of Service Area Coverage?
Does (13627VT0390001) Health Insurance Plan, Variant (13627VT0390001-03) offer Disease Management Programs?
Does BCBSVT Vermont Select Gold CDHP Plan Health Insurance Plan, Variant (13627VT0390001-03) offer Disease Management Programs for Asthma?
Does BCBSVT Vermont Select Gold CDHP Plan Health Insurance Plan, Variant (13627VT0390001-03) offer Disease Management Programs for Heart disease?
Does BCBSVT Vermont Select Gold CDHP Plan Health Insurance Plan, Variant (13627VT0390001-03) offer Disease Management Programs for Depression?
Does BCBSVT Vermont Select Gold CDHP Plan Health Insurance Plan, Variant (13627VT0390001-03) offer Disease Management Programs for Diabetes?
Does BCBSVT Vermont Select Gold CDHP Plan Health Insurance Plan, Variant (13627VT0390001-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does BCBSVT Vermont Select Gold CDHP Plan Health Insurance Plan, Variant (13627VT0390001-03) 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