Complete HMO 20/40 - 41304MA0042039 Health Insurance Plan
Mass General Brigham Health Plan health insurance plan with the Plan ID 41304MA0042039. The plan is called Complete HMO 20/40.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 90.35% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 9.65% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 41304MA0042039 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Massachusetts | ||||||||||||||||||
| Health Insurance Issuer | Mass General Brigham Health Plan | ||||||||||||||||||
| Health Insurance Plan Variant | 41304MA0042039-01 | ||||||||||||||||||
| Provider Network(s) | ['MAN001'] | ||||||||||||||||||
| 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 | |||||||||||||||||||
| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Standard Platinum: Complete HMO 20/40 Health Insurance Plan Variant 41304MA0042039-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Platinum On Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Pregnancy, Weight Loss Programs, Pain Management, Depression, Diabetes, Heart Disease, Asthma |
| First Tier Utilization | 100% |
| Formulary ID | MAF001 |
| HIOS Product ID | 41304MA004 |
| HSA/HRA Employer Contribution | No |
| Import Date | 2/12/2024 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 90.35% |
| Issuer ID | 41304 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Platinum |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MAN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Urgent and Emergency only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Urgent and Emergency only |
| Plan Effective Date | 1/1/2024 |
| Plan ID (Standard Component ID with Variant) | 41304MA0042039-01 |
| Plan Marketing Name | Complete HMO 20/40 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Standard Platinum: Complete HMO 20/40 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $600 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MAS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All except: Gynecologist or Obstetrician for routine, preventive or urgent care; Family Planning services; Outpatient and Diversionary Behavioral Health Services; Routine Eye Exam; Physical Therapy; Occupational Therapy; Speech Therapy and Emergency Services. |
| Plan ID | 41304MA0042039 |
| State Code | MA |
| 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 | $0 per person | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | $3000 per person | $6000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,000 |
| 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 Complete HMO 20/40 Health Insurance Plan, 41304MA0042039
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Complete HMO 20/40, 41304MA0042039 Health Insurance Plan, 41304MA0042039
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Does Complete HMO 20/40 Health Insurance Plan, 41304MA0042039 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (41304MA0042039) Health Insurance Plan, Variant (41304MA0042039-01) offer Disease Management Programs?
Does (41304MA0042039) Health Insurance Plan, Variant (41304MA0042039-01) have Out Of Country Coverage?
Does (41304MA0042039) Health Insurance Plan, Variant (41304MA0042039-01) have Out of Service Area Coverage?
Does (41304MA0042039) Health Insurance Plan, Variant (41304MA0042039-01) offer Disease Management Programs?
Does Standard Platinum: Complete HMO 20/40 Health Insurance Plan, Variant (41304MA0042039-01) offer Disease Management Programs for Asthma?
Does Standard Platinum: Complete HMO 20/40 Health Insurance Plan, Variant (41304MA0042039-01) offer Disease Management Programs for Heart disease?
Does Standard Platinum: Complete HMO 20/40 Health Insurance Plan, Variant (41304MA0042039-01) offer Disease Management Programs for Depression?
Does Standard Platinum: Complete HMO 20/40 Health Insurance Plan, Variant (41304MA0042039-01) offer Disease Management Programs for Diabetes?
Does Standard Platinum: Complete HMO 20/40 Health Insurance Plan, Variant (41304MA0042039-01) offer Disease Management Programs for Pregnancy?
Does Standard Platinum: Complete HMO 20/40 Health Insurance Plan, Variant (41304MA0042039-01) offer Disease Management Programs for Weight loss programs?
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