BluePreferred PPO Standard Silver $4,850 - 78079DC0210004 Health Insurance Plan
GHMSI, Inc. health insurance plan with the Plan ID 78079DC0210004. The plan is called BluePreferred PPO Standard Silver $4,850.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.04% (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 26.96% 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 | 78079DC0210004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | District of Columbia | ||||||||||||||||||
| Health Insurance Issuer | GHMSI, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 78079DC0210004-04 | ||||||||||||||||||
| Provider Network(s) | ['DCN001'] | ||||||||||||||||||
| 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 - 78079DC0210004-01 Open to Indians below 300% FPL - 78079DC0210004-02 Open to Indians above 300% FPL - 78079DC0210004-03 73% AV Silver Plan - 78079DC0210004-04 |
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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 |
BluePreferred PPO Standard Silver $4,850 A Health Insurance Plan Variant 78079DC0210004-04 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.730436899 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | 73% AV Level Silver 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 | $350 per person | $350 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $350 |
| 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 |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 99% |
| First Tier Utilization | 100% |
| Formulary ID | DCF003 |
| HIOS Product ID | 78079DC021 |
| Import Date | 2/12/2024 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 78079 |
| Market Coverage | Individual |
| 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 | $4050 per person | $8100 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $4,050 |
| Medical EHB Deductible, Out of Network, Family | $8100 per person | $16200 per group |
| Medical EHB Deductible, Out of Network, Individual | $8,100 |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | DCN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | All Covered Services |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | All Covered Services |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 78079DC0210004-04 |
| Plan Marketing Name | BluePreferred PPO Standard Silver $4,850 |
| Plan Type | PPO |
| Plan Variant Marketing Name | BluePreferred PPO Standard Silver $4,850 A |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,190 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $4,050 |
| SBC Scenario, Having a Baby, Limit | $10 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $600 |
| SBC Scenario, Having Diabetes, Deductible | $2,530 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| 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 | 78079DC0210004 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $7200 per person | $14400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $14400 per person | $28800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $14,400 |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of BluePreferred PPO Standard Silver $4,850 Health Insurance Plan, 78079DC0210004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about BluePreferred PPO Standard Silver $4,850, 78079DC0210004 Health Insurance Plan, 78079DC0210004
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Does BluePreferred PPO Standard Silver $4,850 Health Insurance Plan, 78079DC0210004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (78079DC0210004) Health Insurance Plan, Variant (78079DC0210004-04) offer Disease Management Programs?
Does (78079DC0210004) Health Insurance Plan, Variant (78079DC0210004-04) have Out Of Country Coverage?
Does (78079DC0210004) Health Insurance Plan, Variant (78079DC0210004-04) have Out of Service Area Coverage?
Does (78079DC0210004) Health Insurance Plan, Variant (78079DC0210004-04) offer Disease Management Programs?
Does BluePreferred PPO Standard Silver $4,850 A Health Insurance Plan, Variant (78079DC0210004-04) offer Disease Management Programs for Asthma?
Does BluePreferred PPO Standard Silver $4,850 A Health Insurance Plan, Variant (78079DC0210004-04) offer Disease Management Programs for Heart disease?
Does BluePreferred PPO Standard Silver $4,850 A Health Insurance Plan, Variant (78079DC0210004-04) offer Disease Management Programs for Depression?
Does BluePreferred PPO Standard Silver $4,850 A Health Insurance Plan, Variant (78079DC0210004-04) offer Disease Management Programs for Diabetes?
Does BluePreferred PPO Standard Silver $4,850 A Health Insurance Plan, Variant (78079DC0210004-04) offer Disease Management Programs for High blood pressure & high cholesterol?
Does BluePreferred PPO Standard Silver $4,850 A Health Insurance Plan, Variant (78079DC0210004-04) offer Disease Management Programs for Low back pain?
Does BluePreferred PPO Standard Silver $4,850 A Health Insurance Plan, Variant (78079DC0210004-04) 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