Aetna Health of Utah Inc. health insurance plan with the Plan ID 65779NV0120004. The plan is called Bronze: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.81% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.19% of the costs of all covered benefits (according to the Issuer).
Health Insurance Plan ID | 65779NV0120004 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Nevada | ||||||||||||||||||
Health Insurance Issuer | Aetna Health of Utah Inc. | ||||||||||||||||||
Health Insurance Plan Variant | 65779NV0120004-03 | ||||||||||||||||||
Provider Network(s) | ['NVN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 GMT). |
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Available Variants of the Health Plan | Standard On Exchange Plan - 65779NV0120004-01 |
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Last Plan Update Date | Mon, 17 Apr 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Plan Attribute | Value |
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Business Year | 2023 |
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 | Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol |
EHB Percent of Total Premium | 100% |
First Tier Utilization | 100% |
Formulary ID | NVF004 |
HIOS Product ID | 65779NV012 |
Import Date | 4/17/2023 |
HSA Eligible | No |
IsItANewPlan | Existing |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | Yes |
Issuer Actuarial Value | 64.81% |
Issuer ID | 65779 |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Expanded Bronze |
Multiple In Network Tiers | No |
National Network | No |
Network ID | NVN001 |
Out of Country Coverage | No |
Out of Service Area Coverage | No |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 65779NV0120004-03 |
Plan Marketing Name | Bronze: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 |
Plan Type | HMO |
Plan Variant Marketing Name | Bronze: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7 |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $200 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $8,700 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $500 |
SBC Scenario, Having Diabetes, Copayment | $0 |
SBC Scenario, Having Diabetes, Deductible | $4,400 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,300 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | NVS001 |
Source Name | SERFF |
Specialist Requiring a Referral | Referral required for all physicians EXCEPT OB/GYN, ER, Internal Medicine, Family Practice, General Medicine and Pediatrician. |
Plan ID | 65779NV0120004 |
State Code | NV |
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 | 50.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $8700 per person | $17400 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $8,700 |
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 | $8850 per person | $17700 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,850 |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 20 Aug 2024 06:14 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