HMO HSA Bronze 5400 - 96667ME0310125 Health Insurance Plan
Harvard Pilgrim Healthcare, Inc. health insurance plan with the Plan ID 96667ME0310125. The plan is called HMO HSA Bronze 5400.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.97% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.03% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 96667ME0310125 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Maine | ||||||||||||||||||
| Health Insurance Issuer | Harvard Pilgrim Healthcare, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 96667ME0310125-01 | ||||||||||||||||||
| Provider Network(s) | ['MEN001'] | ||||||||||||||||||
| 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 - 96667ME0310125-01 |
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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 HSA Bronze 5400 Health Insurance Plan Variant 96667ME0310125-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 99% |
| First Tier Utilization | 100% |
| Formulary ID | MEF012 |
| HIOS Product ID | 96667ME031 |
| Import Date | 2/12/2024 |
| HSA Eligible | Yes |
| IsItANewPlan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 64.97% |
| Issuer ID | 96667 |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MEN001 |
| 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) | 96667ME0310125-01 |
| Plan Marketing Name | HMO HSA Bronze 5400 |
| Plan Type | HMO |
| Plan Variant Marketing Name | HMO HSA Bronze 5400 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,200 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $5,400 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $40 |
| SBC Scenario, Having Diabetes, Deductible | $5,400 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MES003 |
| Source Name | SERFF |
| Specialist Requiring a Referral | A Referral is Needed for all Specialist except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers. |
| Specialty Drug Maximum Coinsurance | $600 |
| Plan ID | 96667ME0310125 |
| State Code | ME |
| 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 | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $5400 per person | $10800 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,400 |
| 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 | $7800 per person | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| 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 HSA Bronze 5400 Health Insurance Plan, 96667ME0310125
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about HMO HSA Bronze 5400, 96667ME0310125 Health Insurance Plan, 96667ME0310125
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Does HMO HSA Bronze 5400 Health Insurance Plan, 96667ME0310125 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (96667ME0310125) Health Insurance Plan, Variant (96667ME0310125-01) offer Disease Management Programs?
Does (96667ME0310125) Health Insurance Plan, Variant (96667ME0310125-01) have Out Of Country Coverage?
Does (96667ME0310125) Health Insurance Plan, Variant (96667ME0310125-01) have Out of Service Area Coverage?
Does (96667ME0310125) Health Insurance Plan, Variant (96667ME0310125-01) offer Disease Management Programs?
Does HMO HSA Bronze 5400 Health Insurance Plan, Variant (96667ME0310125-01) offer Disease Management Programs for Asthma?
Does HMO HSA Bronze 5400 Health Insurance Plan, Variant (96667ME0310125-01) offer Disease Management Programs for Heart disease?
Does HMO HSA Bronze 5400 Health Insurance Plan, Variant (96667ME0310125-01) offer Disease Management Programs for Depression?
Does HMO HSA Bronze 5400 Health Insurance Plan, Variant (96667ME0310125-01) offer Disease Management Programs for Diabetes?
Does HMO HSA Bronze 5400 Health Insurance Plan, Variant (96667ME0310125-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does HMO HSA Bronze 5400 Health Insurance Plan, Variant (96667ME0310125-01) offer Disease Management Programs for Low back pain?
Does HMO HSA Bronze 5400 Health Insurance Plan, Variant (96667ME0310125-01) offer Disease Management Programs for Pregnancy?
Does HMO HSA Bronze 5400 Health Insurance Plan, Variant (96667ME0310125-01) offer Disease Management Programs for Weight loss programs?
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