Keystone HMO Gold - 33871PA0040002 Health Insurance Plan
Keystone Health Plan East health insurance plan with the Plan ID 33871PA0040002. The plan is called Keystone HMO Gold.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.09% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.91% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 33871PA0040002 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Pennsylvania | ||||||||||||||||||
| Health Insurance Issuer | Keystone Health Plan East | ||||||||||||||||||
| Health Insurance Plan Variant | 33871PA0040002-01 | ||||||||||||||||||
| Provider Network(s) | ['PAN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 26 Nov 2024 06:27 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 33871PA0040002-01 |
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| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 26 Nov 2024 06:27 GMT |
Keystone HMO Gold Health Insurance Plan Variant 33871PA0040002-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-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 | 50.00% |
| 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 | 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, Low Back Pain, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 100% |
| First Tier Utilization | 100% |
| Formulary ID | PAF004 |
| HIOS Product ID | 33871PA004 |
| Import Date | 2/12/2024 |
| Inpatient Copayment Maximum Days | 5 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 81.09% |
| Issuer ID | 33871 |
| 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 | 20.00% |
| 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 | 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 | PAN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Effective Date | 1/1/2024 |
| Plan ID (Standard Component ID with Variant) | 33871PA0040002-01 |
| Plan Level Exclusions | Acupuncture, Bariatric Surgery, Cosmetic Surgery, Dental Care (Adult), Hearing Aids, Long-term Care, Private Duty Nursing, Routine eye care (Adult), Routine foot care, Weight Loss programs, Non-emergency care when traveling outside the U.S., Most coverage provided outside the U.S. |
| Plan Marketing Name | Keystone HMO Gold |
| Plan Type | HMO |
| Plan Variant Marketing Name | Keystone HMO Gold |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $800 |
| SBC Scenario, Having a Baby, Copayment | $1,600 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $20 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $2,500 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $70 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $800 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | PAS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | Referrals are required for all services except: Emergency Services, OB/GYN, Mammograms, Inpatient Hospital Services, Dialysis services performed in a Participating Facility or by a Participating Professional Provider, Nutrition Counseling and Diabetic Education Program |
| Specialty Drug Maximum Coinsurance | $1,000 |
| Plan ID | 33871PA0040002 |
| State Code | PA |
| 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 | $8000 per person | $16000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,000 |
| 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 | No |
Copay & Coinsurance of Keystone HMO Gold Health Insurance Plan, 33871PA0040002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Keystone HMO Gold, 33871PA0040002 Health Insurance Plan, 33871PA0040002
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Does Keystone HMO Gold Health Insurance Plan, 33871PA0040002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (33871PA0040002) Health Insurance Plan, Variant (33871PA0040002-01) offer Disease Management Programs?
Does (33871PA0040002) Health Insurance Plan, Variant (33871PA0040002-01) have Out Of Country Coverage?
Does (33871PA0040002) Health Insurance Plan, Variant (33871PA0040002-01) have Out of Service Area Coverage?
Does (33871PA0040002) Health Insurance Plan, Variant (33871PA0040002-01) offer Disease Management Programs?
Does Keystone HMO Gold Health Insurance Plan, Variant (33871PA0040002-01) offer Disease Management Programs for Asthma?
Does Keystone HMO Gold Health Insurance Plan, Variant (33871PA0040002-01) offer Disease Management Programs for Heart disease?
Does Keystone HMO Gold Health Insurance Plan, Variant (33871PA0040002-01) offer Disease Management Programs for Depression?
Does Keystone HMO Gold Health Insurance Plan, Variant (33871PA0040002-01) offer Disease Management Programs for Diabetes?
Does Keystone HMO Gold Health Insurance Plan, Variant (33871PA0040002-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Keystone HMO Gold Health Insurance Plan, Variant (33871PA0040002-01) offer Disease Management Programs for Low back pain?
Does Keystone HMO Gold Health Insurance Plan, Variant (33871PA0040002-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 26 Nov 2024 06:27 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