Elite ePPO Basic - 54965VA0070001 Health Insurance Plan
54965 health insurance plan with the Plan ID 54965VA0070001. The plan is called Elite ePPO Basic.
| Health Insurance Plan ID | 54965VA0070001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Virginia | ||||||||||||||||||
| Health Insurance Issuer | 54965 | ||||||||||||||||||
| Health Insurance Plan Variant | 54965VA0070001-01 | ||||||||||||||||||
| Provider Network(s) | ELITE | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Sep 2024 06:34 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 | Tue, 10 Sep 2024 06:34 GMT |
Elite ePPO Basic Health Insurance Plan Variant 54965VA0070001-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Low On Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 100.00% |
| First Tier Utilization | 100% |
| HIOS Product ID | 54965VA007 |
| Import Date | 2/12/2024 |
| Guaranteed Rate | Guaranteed Rate |
| IsItANewPlan | Existing |
| Issuer ID | 54965 |
| Market Coverage | Individual |
| 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 | $100 per person | $200 per group |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $100 |
| Medical EHB Deductible, In Network (Tier 1), Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, In Network (Tier 1), Individual | Not Applicable |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family | $400 per person | $800 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $400 |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual | Not Applicable |
| Metal Level | Low |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | VAN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency pain treatment only if 50 miles away from home zip code, up to $100 |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency pain treatment only if 50 miles away from home zip code, up to $100 |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 54965VA0070001-01 |
| Plan Level Exclusions | Out of Pocket Maximum applies to children only. Adults have separate deductible and plan payment maximum, refer to plan document for details. Co-insurance equivalent percentages displayed except for orthodontic services; copay for orthodontic services will not equal more than out of pocket maximum. |
| Plan Marketing Name | Elite ePPO Basic |
| Plan Type | PPO |
| Plan Variant Marketing Name | Elite ePPO Basic |
| QHP/Non QHP | Both |
| Service Area ID | VAS002 |
| Source Name | SERFF |
| Plan ID | 54965VA0070001 |
| State Code | VA |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Elite ePPO Basic Health Insurance Plan, 54965VA0070001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Elite ePPO Basic, 54965VA0070001 Health Insurance Plan, 54965VA0070001
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Does Elite ePPO Basic Health Insurance Plan, 54965VA0070001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (54965VA0070001) Health Insurance Plan, Variant (54965VA0070001-01) have Out Of Country Coverage?
Yes. Details: Emergency pain treatment only if 50 miles away from home zip code, up to $100
Does (54965VA0070001) Health Insurance Plan, Variant (54965VA0070001-01) have Out of Service Area Coverage?
Yes. Details: Emergency pain treatment only if 50 miles away from home zip code, up to $100
Disclaimer: This is based on the import(Date: Tue, 10 Sep 2024 06:34 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