Gold 1 with Low Cost Generic Drugs - 19722NM0010001 Health Insurance Plan
Molina Healthcare of New Mexico, Inc. health insurance plan with the Plan ID 19722NM0010001. The plan is called Gold 1 with Low Cost Generic Drugs.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.71% (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 20.29% 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 | 19722NM0010001 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | New Mexico | ||||||||||||||||||
| Health Insurance Issuer | Molina Healthcare of New Mexico, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 19722NM0010001-03 | ||||||||||||||||||
| Provider Network(s) | ['NMN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 17 Dec 2024 06:12 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 19722NM0010001-01 |
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| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 17 Dec 2024 06:12 GMT |
Native American Gold 1 LCS with Low Cost Generic Drugs Health Insurance Plan Variant 19722NM0010001-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.797070009 |
| 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 |
| EHB Percent of Total Premium | 100% |
| First Tier Utilization | 100% |
| Formulary ID | NMF001 |
| HIOS Product ID | 19722NM001 |
| Import Date | 2/12/2024 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 19722 |
| 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 | NMN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 19722NM0010001-03 |
| Plan Marketing Name | Gold 1 with Low Cost Generic Drugs |
| Plan Type | HMO |
| Plan Variant Marketing Name | Native American Gold 1 LCS with Low Cost Generic Drugs |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,500 |
| SBC Scenario, Having a Baby, Copayment | $300 |
| SBC Scenario, Having a Baby, Deductible | $1,550 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $1,550 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $40 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,550 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NMS001 |
| Source Name | SERFF |
| Plan ID | 19722NM0010001 |
| State Code | NM |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $1550 per person | $3100 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,550 |
| 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 | $8100 per person | $16200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,100 |
| 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 | No |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Gold 1 with Low Cost Generic Drugs Health Insurance Plan, 19722NM0010001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Gold 1 with Low Cost Generic Drugs, 19722NM0010001 Health Insurance Plan, 19722NM0010001
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Does Gold 1 with Low Cost Generic Drugs Health Insurance Plan, 19722NM0010001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (19722NM0010001) Health Insurance Plan, Variant (19722NM0010001-03) have Out Of Country Coverage?
Does (19722NM0010001) Health Insurance Plan, Variant (19722NM0010001-03) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 17 Dec 2024 06:12 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