Elite PPO Basic - 54965VA0030004 Health Insurance Plan
54965 health insurance plan with the Plan ID 54965VA0030004. The plan is called Elite PPO Basic.
| Health Insurance Plan ID | 54965VA0030004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Virginia | ||||||||||||||||||
| Health Insurance Issuer | 54965 | ||||||||||||||||||
| Health Insurance Plan Variant | 54965VA0030004-01 | ||||||||||||||||||
| Provider Network(s) | ELITE | ||||||||||||||||||
| 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 | |||||||||||||||||||
| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 24 Dec 2024 06:21 GMT |
Elite PPO Basic Health Insurance Plan Variant 54965VA0030004-01 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 | 54965VA003 |
| 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 | Yes |
| Network ID | VAN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Standard Out of Network PPO Benefits |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Standard Out of Network PPO Benefits |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 54965VA0030004-01 |
| 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. |
| Plan Marketing Name | Elite PPO Basic |
| Plan Type | PPO |
| Plan Variant Marketing Name | Elite PPO Basic |
| QHP/Non QHP | Both |
| Service Area ID | VAS002 |
| Source Name | SERFF |
| Plan ID | 54965VA0030004 |
| State Code | VA |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Elite PPO Basic Health Insurance Plan, 54965VA0030004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Elite PPO Basic, 54965VA0030004 Health Insurance Plan, 54965VA0030004
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Does Elite PPO Basic Health Insurance Plan, 54965VA0030004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (54965VA0030004) Health Insurance Plan, Variant (54965VA0030004-01) have Out Of Country Coverage?
Does (54965VA0030004) Health Insurance Plan, Variant (54965VA0030004-01) have Out of Service Area Coverage?
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