GoldPrime-G2, NS 3PCP Gold, INN, Dep25, Family Dental, Family Vision, Healthy Living Rewards, Metro-MP - 11177NY0220001 Health Insurance Plan
MetroPlus health insurance plan with the Plan ID 11177NY0220001. The plan is called GoldPrime-G2, NS 3PCP Gold, INN, Dep25, Family Dental, Family Vision, Healthy Living Rewards, Metro-MP.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.99% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.01% 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 81.99% (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 18.01% 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 | 11177NY0220001 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | MetroPlus | ||||||||||||||||||
| Health Insurance Plan Variant | 11177NY0220001-03 | ||||||||||||||||||
| Provider Network(s) | ['NYN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 11177NY0220001-01 |
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| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 10 Dec 2024 06:32 GMT |
GoldPrime-G2, NS 3PCP Gold, INN, Dep25, Family Dental, Family Vision, Healthy Living Rewards, Metro-MP Health Insurance Plan Variant 11177NY0220001-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.819889776 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 3 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| 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 | 0.00% |
| 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 |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 99% |
| First Tier Utilization | 100% |
| Formulary ID | NYF005 |
| HIOS Product ID | 11177NY022 |
| Import Date | 2/12/2024 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 81.99% |
| Issuer ID | 11177 |
| Market Coverage | Individual |
| 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 | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $650 per person | $1300 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $650 |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | NYN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Only |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 11177NY0220001-03 |
| Plan Marketing Name | GoldPrime-G2, NS 3PCP Gold, INN, Dep25, Family Dental, Family Vision, Healthy Living Rewards, Metro-MP |
| Plan Type | HMO |
| Plan Variant Marketing Name | GoldPrime-G2, NS 3PCP Gold, INN, Dep25, Family Dental, Family Vision, Healthy Living Rewards, Metro-MP |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $2,405 |
| SBC Scenario, Having a Baby, Deductible | $650 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $346 |
| SBC Scenario, Having Diabetes, Copayment | $1,740 |
| SBC Scenario, Having Diabetes, Deductible | $650 |
| SBC Scenario, Having Diabetes, Limit | $55 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $7 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,315 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $650 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NYS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All specialists with the exception of assigned Primary and preventive obstetric and gynecologic provider |
| Plan ID | 11177NY0220001 |
| 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 | $7250 per person | $14500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,250 |
| 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 | No |
Copay & Coinsurance of GoldPrime-G2, NS 3PCP Gold, INN, Dep25, Family Dental, Family Vision, Healthy Living Rewards, Metro-MP Health Insurance Plan, 11177NY0220001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about GoldPrime-G2, NS 3PCP Gold, INN, Dep25, Family Dental, Family Vision, Healthy Living Rewards, Metro-MP, 11177NY0220001 Health Insurance Plan, 11177NY0220001
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Does GoldPrime-G2, NS 3PCP Gold, INN, Dep25, Family Dental, Family Vision, Healthy Living Rewards, Metro-MP Health Insurance Plan, 11177NY0220001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (11177NY0220001) Health Insurance Plan, Variant (11177NY0220001-03) have Out Of Country Coverage?
Does (11177NY0220001) Health Insurance Plan, Variant (11177NY0220001-03) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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