Complete Gold + Vision + Adult Dental - 86199PA0020025 Health Insurance Plan
Pennsylvania Health & Wellness Inc. health insurance plan with the Plan ID 86199PA0020025. The plan is called Complete Gold + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 80.76% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.24% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 86199PA0020025 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Pennsylvania | ||||||||||||||||||
| Health Insurance Issuer | Pennsylvania Health & Wellness Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 86199PA0020025-01 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| 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 - 86199PA0020025-01 |
||||||||||||||||||
| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Complete Gold + Vision + Adult Dental Health Insurance Plan Variant 86199PA0020025-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Pregnancy, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 96% |
| First Tier Utilization | 100% |
| Formulary ID | PAF003 |
| HIOS Product ID | 86199PA002 |
| Import Date | 2/12/2024 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 80.76% |
| Issuer ID | 86199 |
| 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 | No |
| Network ID | PAN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Effective Date | 1/1/2024 |
| Plan ID (Standard Component ID with Variant) | 86199PA0020025-01 |
| Plan Marketing Name | Complete Gold + Vision + Adult Dental |
| Plan Type | HMO |
| Plan Variant Marketing Name | Complete Gold + Vision + Adult Dental |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,500 |
| SBC Scenario, Having a Baby, Copayment | $300 |
| SBC Scenario, Having a Baby, Deductible | $1,450 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $800 |
| SBC Scenario, Having Diabetes, Deductible | $800 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,450 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | PAS001 |
| Source Name | SERFF |
| Plan ID | 86199PA0020025 |
| State Code | PA |
| 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 | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $1450 per person | $2900 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,450 |
| 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 | $7500 per person | $15000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,500 |
| 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 | No |
Copay & Coinsurance of Complete Gold + Vision + Adult Dental Health Insurance Plan, 86199PA0020025
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Complete Gold + Vision + Adult Dental, 86199PA0020025 Health Insurance Plan, 86199PA0020025
-
Does Complete Gold + Vision + Adult Dental Health Insurance Plan, 86199PA0020025 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (86199PA0020025) Health Insurance Plan, Variant (86199PA0020025-01) offer Disease Management Programs?
Does (86199PA0020025) Health Insurance Plan, Variant (86199PA0020025-01) have Out Of Country Coverage?
Does (86199PA0020025) Health Insurance Plan, Variant (86199PA0020025-01) have Out of Service Area Coverage?
Does (86199PA0020025) Health Insurance Plan, Variant (86199PA0020025-01) offer Disease Management Programs?
Does Complete Gold + Vision + Adult Dental Health Insurance Plan, Variant (86199PA0020025-01) offer Disease Management Programs for Asthma?
Does Complete Gold + Vision + Adult Dental Health Insurance Plan, Variant (86199PA0020025-01) offer Disease Management Programs for Heart disease?
Does Complete Gold + Vision + Adult Dental Health Insurance Plan, Variant (86199PA0020025-01) offer Disease Management Programs for Diabetes?
Does Complete Gold + Vision + Adult Dental Health Insurance Plan, Variant (86199PA0020025-01) 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