HMO Hybrid 228 Gold, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP, FP - 94788NY0260126 Health Insurance Plan

CDPHP health insurance plan with the Plan ID 94788NY0260126. The plan is called HMO Hybrid 228 Gold, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP, FP.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.54% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.46% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 94788NY0260126
Health Insurance Plan Year 2024
State New York
Health Insurance Issuer CDPHP
Health Insurance Plan Variant 94788NY0260126-01
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).

Providers New York All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard On Exchange Plan - 94788NY0260126-01

Last Plan Update Date Mon, 12 Feb 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

HMO Hybrid 228 Gold, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP, FP Health Insurance Plan Variant 94788NY0260126-01 Attributes

Plan Attribute Value
Business Year 2024
Child-Only Offering Allows Adult-Only
Composite Rating Offered No
CSR Variation Type Standard Gold On Exchange Plan
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 per person not applicable | per group not applicable
Drug EHB Deductible, In Network (Tier 1), Individual Not Applicable
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 NYF019
HIOS Product ID 94788NY026
HSA/HRA Employer Contribution No
Import Date 2/12/2024
HSA Eligible No
IsItANewPlan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? Yes
Issuer Actuarial Value 81.54%
Issuer ID 94788
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 0.00%
Medical EHB Deductible, In Network (Tier 1), Family $800 per person | $1600 per group
Medical EHB Deductible, In Network (Tier 1), Individual $800
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) 94788NY0260126-01
Plan Marketing Name HMO Hybrid 228 Gold, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP, FP
Plan Type HMO
Plan Variant Marketing Name HMO Hybrid 228 Gold, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP, FP
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,818
SBC Scenario, Having a Baby, Copayment $460
SBC Scenario, Having a Baby, Deductible $800
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $1,966
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $800
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $40
SBC Scenario, Treatment of a Simple Fracture, Copayment $250
SBC Scenario, Treatment of a Simple Fracture, Deductible $800
SBC Scenario, Treatment of a Simple Fracture, Limit $212
Service Area ID NYS001
Source Name SERFF
Specialist Requiring a Referral All
Plan ID 94788NY0260126
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 $8250 per person | $16500 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,250
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 Hybrid 228 Gold, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP, FP Health Insurance Plan, 94788NY0260126

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about HMO Hybrid 228 Gold, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP, FP, 94788NY0260126 Health Insurance Plan, 94788NY0260126

  • Does HMO Hybrid 228 Gold, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP, FP Health Insurance Plan, 94788NY0260126 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (94788NY0260126) Health Insurance Plan, Variant (94788NY0260126-01) have Out Of Country Coverage?

    Yes. Details: Emergency Only

    Does (94788NY0260126) Health Insurance Plan, Variant (94788NY0260126-01) have Out of Service Area Coverage?

    Yes. Details: Emergency Only

 

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