Presbyterian Health Plan health insurance plan with the Plan ID 57173NM0310002. The plan is called Ind HDHP/HSA Silver 2 with GYM.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.80% (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 5.20% 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 | 57173NM0310002 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | New Mexico | ||||||||||||||||||
Health Insurance Issuer | Presbyterian Health Plan | ||||||||||||||||||
Health Insurance Plan Variant | 57173NM0310002-06 | ||||||||||||||||||
Provider Network(s) | ['NMN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 GMT). |
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Available Variants of the Health Plan | Standard On Exchange Plan - 57173NM0310002-01 Open to Indians below 300% FPL - 57173NM0310002-02 Open to Indians above 300% FPL - 57173NM0310002-03 73% AV Silver Plan - 57173NM0310002-04 |
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Last Plan Update Date | Tue, 09 May 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Plan Attribute | Value |
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AV Calculator Output Number | 0.948036543 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | 94% AV Level Silver Plan |
Dental Only Plan | No |
Design Type | Not Applicable |
Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol |
EHB Percent of Total Premium | 98.82% |
First Tier Utilization | 100% |
Formulary ID | NMF027 |
HIOS Product ID | 57173NM031 |
Import Date | 5/9/2023 |
HSA Eligible | No |
IsItANewPlan | Existing |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
Issuer ID | 57173 |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Silver |
Multiple In Network Tiers | No |
National Network | Yes |
Network ID | NMN001 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Emergency and non-Emergency when Prior Authorization is obtained |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Emergency and non-Emergency when Prior Authorization is obtained |
Plan Effective Date | 1/1/2023 |
Plan ID (Standard Component ID with Variant) | 57173NM0310002-06 |
Plan Marketing Name | Ind HDHP/HSA Silver 2 with GYM |
Plan Type | HMO |
Plan Variant Marketing Name | Ind HMO Silver 2 with EXTRA SAVINGS 94% and GYM |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $500 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $250 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $200 |
SBC Scenario, Having Diabetes, Copayment | $300 |
SBC Scenario, Having Diabetes, Deductible | $250 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $250 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | NMS001 |
Source Name | SERFF |
Plan ID | 57173NM0310002 |
State Code | NM |
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 | 10.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $250 per person | $500 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $250 |
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 | $700 per person | $1400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $700 |
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 | No |
Version Number | 1 |
Wellness Program Offered | Yes |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 20 Aug 2024 06:14 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