BluePreferred PPO Value Gold $1,000 - 94084MD0130010 Health Insurance Plan
GHMSI, Inc. health insurance plan with the Plan ID 94084MD0130010. The plan is called BluePreferred PPO Value Gold $1,000.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.20% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.80% 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 81.20% (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 18.80% 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 | 94084MD0130010 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Maryland | ||||||||||||||||||
| Health Insurance Issuer | GHMSI, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 94084MD0130010-03 | ||||||||||||||||||
| Provider Network(s) | ['MDN002'] | ||||||||||||||||||
| 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 - 94084MD0130010-01 |
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| Last Plan Update Date | Fri, 31 May 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
BluePreferred PPO Value Gold $1,000 Health Insurance Plan Variant 94084MD0130010-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.811980853 |
| 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 | $150 per person | $300 per group |
| Drug EHB Deductible, Combined In/Out of Network, Individual | $150 |
| 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 |
| Maximum Out of Pocket for Drug EHB Benefits, In Network (Tier 1), Individual | $600 |
| Maximum Out of Pocket for Drug EHB Benefits, In Network (Tier 2), Individual | $600 per person | $1200 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, Low Back Pain, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 99% |
| First Tier Utilization | 100% |
| Formulary ID | MDF008 |
| HIOS Product ID | 94084MD013 |
| Import Date | 5/31/2024 |
| HSA Eligible | No |
| IsItANewPlan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 81.20% |
| Issuer ID | 94084 |
| 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 | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $1000 per person | $2000 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,000 |
| Medical EHB Deductible, Out of Network, Family | $2000 per person | $4000 per group |
| Medical EHB Deductible, Out of Network, Individual | $2,000 |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family | $6750 per person | $13500 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $6,750 |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family | $13500 per person | $27000 per group |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual | $13,500 |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | MDN002 |
| 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) | 94084MD0130010-03 |
| Plan Marketing Name | BluePreferred PPO Value Gold $1,000 |
| Plan Type | PPO |
| Plan Variant Marketing Name | BluePreferred PPO Value Gold $1,000 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $900 |
| SBC Scenario, Having a Baby, Deductible | $1,750 |
| SBC Scenario, Having a Baby, Limit | $10 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $650 |
| SBC Scenario, Having Diabetes, Deductible | $1,400 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $34 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $260 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,750 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MDS006 |
| Source Name | SERFF |
| Plan ID | 94084MD0130010 |
| State Code | MD |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of BluePreferred PPO Value Gold $1,000 Health Insurance Plan, 94084MD0130010
| 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 Value Gold $1,000, 94084MD0130010 Health Insurance Plan, 94084MD0130010
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Does BluePreferred PPO Value Gold $1,000 Health Insurance Plan, 94084MD0130010 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (94084MD0130010) Health Insurance Plan, Variant (94084MD0130010-03) offer Disease Management Programs?
Does (94084MD0130010) Health Insurance Plan, Variant (94084MD0130010-03) have Out Of Country Coverage?
Does (94084MD0130010) Health Insurance Plan, Variant (94084MD0130010-03) have Out of Service Area Coverage?
Does (94084MD0130010) Health Insurance Plan, Variant (94084MD0130010-03) offer Disease Management Programs?
Does BluePreferred PPO Value Gold $1,000 Health Insurance Plan, Variant (94084MD0130010-03) offer Disease Management Programs for Asthma?
Does BluePreferred PPO Value Gold $1,000 Health Insurance Plan, Variant (94084MD0130010-03) offer Disease Management Programs for Heart disease?
Does BluePreferred PPO Value Gold $1,000 Health Insurance Plan, Variant (94084MD0130010-03) offer Disease Management Programs for Depression?
Does BluePreferred PPO Value Gold $1,000 Health Insurance Plan, Variant (94084MD0130010-03) offer Disease Management Programs for Diabetes?
Does BluePreferred PPO Value Gold $1,000 Health Insurance Plan, Variant (94084MD0130010-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does BluePreferred PPO Value Gold $1,000 Health Insurance Plan, Variant (94084MD0130010-03) offer Disease Management Programs for Low back pain?
Does BluePreferred PPO Value Gold $1,000 Health Insurance Plan, Variant (94084MD0130010-03) 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