Elite Gold + Vision + Adult Dental - 45142NV0030031 Health Insurance Plan
SilverSummit Healthplan Inc. health insurance plan with the Plan ID 45142NV0030031. The plan is called Elite Gold + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.62% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.38% 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 82.64% (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 17.36% 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 | 45142NV0030031 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Nevada | ||||||||||||||||||
| Health Insurance Issuer | SilverSummit Healthplan Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 45142NV0030031-03 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 45142NV0030031-01 |
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| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 24 Dec 2024 06:21 GMT |
Elite Gold + Vision + Adult Dental Health Insurance Plan Variant 45142NV0030031-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.826354759 |
| Business Year | 2024 |
| 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 | Pregnancy, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 95% |
| First Tier Utilization | 100% |
| Formulary ID | NVF009 |
| HIOS Product ID | 45142NV003 |
| 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 | 81.62% |
| Issuer ID | 45142 |
| 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 | NVN001 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Except for Emergecies |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Except for Emergecies |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 45142NV0030031-03 |
| Plan Marketing Name | Elite Gold + Vision + Adult Dental |
| Plan Type | HMO |
| Plan Variant Marketing Name | Elite Gold + Vision + Adult Dental |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| 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 | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NVS001 |
| Source Name | SERFF |
| Plan ID | 45142NV0030031 |
| 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 | 30.00% |
| 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 | $5500 per person | $11000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,500 |
| 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 | Yes |
Copay & Coinsurance of Elite Gold + Vision + Adult Dental Health Insurance Plan, 45142NV0030031
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Elite Gold + Vision + Adult Dental, 45142NV0030031 Health Insurance Plan, 45142NV0030031
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Does Elite Gold + Vision + Adult Dental Health Insurance Plan, 45142NV0030031 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (45142NV0030031) Health Insurance Plan, Variant (45142NV0030031-03) offer Disease Management Programs?
Does (45142NV0030031) Health Insurance Plan, Variant (45142NV0030031-03) have Out Of Country Coverage?
Does (45142NV0030031) Health Insurance Plan, Variant (45142NV0030031-03) have Out of Service Area Coverage?
Does (45142NV0030031) Health Insurance Plan, Variant (45142NV0030031-03) offer Disease Management Programs?
Does Elite Gold + Vision + Adult Dental Health Insurance Plan, Variant (45142NV0030031-03) offer Disease Management Programs for Asthma?
Does Elite Gold + Vision + Adult Dental Health Insurance Plan, Variant (45142NV0030031-03) offer Disease Management Programs for Heart disease?
Does Elite Gold + Vision + Adult Dental Health Insurance Plan, Variant (45142NV0030031-03) offer Disease Management Programs for Diabetes?
Does Elite Gold + Vision + Adult Dental Health Insurance Plan, Variant (45142NV0030031-03) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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