EmblemHealth Insurance Company health insurance plan with the Plan ID 20984NY0460001. The plan is called EmblemHealth Gold PPO-N, Gold, OON, Bridge Program non-gated, Dep25, 3 Free PCP, No Deductible All Drugs, Free Telemedicine and Acupuncture, Pediatric Vision, Pediatric Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 79.67% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 20.33% of the costs of all covered benefits (according to the Issuer).
Health Insurance Plan ID | 20984NY0460001 | ||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | New York | ||||||||||||||||||
Health Insurance Issuer | EmblemHealth Insurance Company | ||||||||||||||||||
Health Insurance Plan Variant | 20984NY0460001-01 | ||||||||||||||||||
Provider Network(s) | ['NYN007'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 GMT). |
|
||||||||||||||||||
Available Variants of the Health Plan | |||||||||||||||||||
Last Plan Update Date | Mon, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Plan Attribute | Value |
---|---|
Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 100.00% |
Drug EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
Drug EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
Drug EHB Deductible, Out of Network, Individual | Not Applicable |
Dental Only Plan | No |
First Tier Utilization | 100% |
Formulary ID | NYF002 |
HIOS Product ID | 20984NY046 |
HSA/HRA Employer Contribution | No |
Import Date | 1/23/2023 |
HSA Eligible | No |
IsItANewPlan | Existing |
Notice Required for Pregnancy | Yes |
Is a Referral Required for Specialist? | No |
Issuer Actuarial Value | 79.67% |
Issuer ID | 20984 |
Market Coverage | SHOP (Small Group) |
Medical Drug Deductibles Integrated | No |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Medical EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 100.00% |
Medical EHB Deductible, In Network (Tier 1), Family | $1500 per person | $3000 per group |
Medical EHB Deductible, In Network (Tier 1), Individual | $1,500 |
Medical EHB Deductible, Out of Network, Family | $3800 per person | $7600 per group |
Medical EHB Deductible, Out of Network, Individual | $3,800 |
Metal Level | Gold |
Multiple In Network Tiers | No |
National Network | No |
Network ID | NYN007 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Emegency Only |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Emergency Only |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 20984NY0460001-01 |
Plan Level Exclusions | No |
Plan Marketing Name | EmblemHealth Gold PPO-N, Gold, OON, Bridge Program non-gated, Dep25, 3 Free PCP, No Deductible All Drugs, Free Telemedicine and Acupuncture, Pediatric Vision, Pediatric Dental |
Plan Type | PPO |
Plan Variant Marketing Name | EmblemHealth Gold PPO-N, Gold, OON, Bridge Program non-gated, Dep25, 3 Free PCP, No Deductible All Drugs, Free Telemedicine and Acupuncture, Pediatric Vision, Pediatric Dental |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $3,280 |
SBC Scenario, Having a Baby, Copayment | $720 |
SBC Scenario, Having a Baby, Deductible | $1,000 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $346 |
SBC Scenario, Having Diabetes, Copayment | $1,375 |
SBC Scenario, Having Diabetes, Deductible | $1,000 |
SBC Scenario, Having Diabetes, Limit | $55 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $245 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $920 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $763 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | NYS001 |
Source Name | SERFF |
Plan ID | 20984NY0460001 |
State Code | NY |
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 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $6200 per person | $12400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,200 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $8000 per person | $16000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $8,000 |
Unique Plan Design | Yes |
Version Number | 1 |
Wellness Program Offered | Yes |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
---|
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 20 Aug 2024 06:14 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