HMO Blue Deductible with Copayment - 42690MA1290077 Health Insurance Plan
Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc health insurance plan with the Plan ID 42690MA1290077. The plan is called HMO Blue Deductible with Copayment.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 79.66% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 20.34% 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 78.05% (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 21.95% 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 | 42690MA1290077 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Massachusetts | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc | ||||||||||||||||||
| Health Insurance Plan Variant | 42690MA1290077-03 | ||||||||||||||||||
| Provider Network(s) | ['MAN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 42690MA1290077-01 |
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| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
HMO Blue Deductible with Copayment Health Insurance Plan Variant 42690MA1290077-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.780470444 |
| 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 | $250 per person | $500 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $250 |
| 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 |
| Disease Management Programs Offered | Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 99% |
| First Tier Utilization | 100% |
| Formulary ID | MAF003 |
| HIOS Product ID | 42690MA129 |
| 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 | 79.66% |
| Issuer ID | 42690 |
| 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 | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $2000 per person | $4000 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| 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 | MAN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency and Urgent Care Services only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency and Urgent Care Services only |
| Plan Effective Date | 1/1/2024 |
| Plan ID (Standard Component ID with Variant) | 42690MA1290077-03 |
| Plan Marketing Name | HMO Blue Deductible with Copayment |
| Plan Type | HMO |
| Plan Variant Marketing Name | HMO Blue Deductible with Copayment |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $900 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,500 |
| SBC Scenario, Having Diabetes, Deductible | $400 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,900 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MAS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All professional provider specialists except for OB/GYN, Chiropractor, and Acupuncturist |
| Plan ID | 42690MA1290077 |
| State Code | MA |
| 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 | $5250 per person | $10500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,250 |
| 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 | Yes |
Copay & Coinsurance of HMO Blue Deductible with Copayment Health Insurance Plan, 42690MA1290077
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about HMO Blue Deductible with Copayment, 42690MA1290077 Health Insurance Plan, 42690MA1290077
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Does HMO Blue Deductible with Copayment Health Insurance Plan, 42690MA1290077 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (42690MA1290077) Health Insurance Plan, Variant (42690MA1290077-03) offer Disease Management Programs?
Does (42690MA1290077) Health Insurance Plan, Variant (42690MA1290077-03) have Out Of Country Coverage?
Does (42690MA1290077) Health Insurance Plan, Variant (42690MA1290077-03) have Out of Service Area Coverage?
Does (42690MA1290077) Health Insurance Plan, Variant (42690MA1290077-03) offer Disease Management Programs?
Does HMO Blue Deductible with Copayment Health Insurance Plan, Variant (42690MA1290077-03) offer Disease Management Programs for Asthma?
Does HMO Blue Deductible with Copayment Health Insurance Plan, Variant (42690MA1290077-03) offer Disease Management Programs for Heart disease?
Does HMO Blue Deductible with Copayment Health Insurance Plan, Variant (42690MA1290077-03) offer Disease Management Programs for Depression?
Does HMO Blue Deductible with Copayment Health Insurance Plan, Variant (42690MA1290077-03) offer Disease Management Programs for Diabetes?
Does HMO Blue Deductible with Copayment Health Insurance Plan, Variant (42690MA1290077-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does HMO Blue Deductible with Copayment Health Insurance Plan, Variant (42690MA1290077-03) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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