HMO Triple Zero Copayment 24, Gold, NS, INN, Dep25, Adult Vision, Lasik, Wellness - 94788NY0280154 Health Insurance Plan

CDPHP health insurance plan with the Plan ID 94788NY0280154. The plan is called HMO Triple Zero Copayment 24, Gold, NS, INN, Dep25, Adult Vision, Lasik, Wellness.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 100.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 94788NY0280154
Health Insurance Plan Year 2024
State New York
Health Insurance Issuer CDPHP
Health Insurance Plan Variant 94788NY0280154-02
Provider Network(s) ['NYN002']
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 - 94788NY0280154-01

Open to Indians below 300% FPL - 94788NY0280154-02

Open to Indians above 300% FPL - 94788NY0280154-03

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

HMO Triple Zero Copayment 24, Gold, NS, INN, Dep25, Adult Vision, Lasik, Wellness Health Insurance Plan Variant 94788NY0280154-02 Attributes

Plan Attribute Value
Business Year 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Zero Cost Sharing Plan Variation
Drug EHB Deductible, Combined In/Out of Network, Family $0 per person | $0 per group
Drug EHB Deductible, Combined In/Out of Network, Individual $0
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 $0 per person | $0 per group
Drug EHB Deductible, Out of Network, Individual $0
Dental Only Plan No
Design Type Not Applicable
EHB Percent of Total Premium 98%
First Tier Utilization 100%
Formulary ID NYF001
HIOS Product ID 94788NY028
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 100.00%
Issuer ID 94788
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 $0 per person | $0 per group
Medical EHB Deductible, Combined In/Out of Network, Individual $0
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Medical EHB Deductible, In Network (Tier 1), Family $0 per person | $0 per group
Medical EHB Deductible, In Network (Tier 1), Individual $0
Medical EHB Deductible, Out of Network, Family $0 per person | $0 per group
Medical EHB Deductible, Out of Network, Individual $0
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID NYN002
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) 94788NY0280154-02
Plan Marketing Name HMO Triple Zero Copayment 24, Gold, NS, INN, Dep25, Adult Vision, Lasik, Wellness
Plan Type HMO
Plan Variant Marketing Name HMO Triple Zero Copayment 24, Gold, NS, INN, Dep25, Adult Vision, Lasik, Wellness
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $2,500
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $864
SBC Scenario, Having Diabetes, Copayment $1,950
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $55
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $18
SBC Scenario, Treatment of a Simple Fracture, Copayment $1,700
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID NYS002
Source Name SERFF
Specialist Requiring a Referral All
Plan ID 94788NY0280154
State Code NY
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family $0 per person | $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family $0 per person | $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family $0 per person | $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $0
Unique Plan Design Yes
Version Number 1
Wellness Program Offered Yes

Copay & Coinsurance of HMO Triple Zero Copayment 24, Gold, NS, INN, Dep25, Adult Vision, Lasik, Wellness Health Insurance Plan, 94788NY0280154

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

Frequently Asked Questions(FAQ) about HMO Triple Zero Copayment 24, Gold, NS, INN, Dep25, Adult Vision, Lasik, Wellness, 94788NY0280154 Health Insurance Plan, 94788NY0280154

  • Does HMO Triple Zero Copayment 24, Gold, NS, INN, Dep25, Adult Vision, Lasik, Wellness Health Insurance Plan, 94788NY0280154 support Mail Ordering?

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

  • Does (94788NY0280154) Health Insurance Plan, Variant (94788NY0280154-02) have Out Of Country Coverage?

    Yes. Details: Emergency Only

    Does (94788NY0280154) Health Insurance Plan, Variant (94788NY0280154-02) 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