KP DC Gold Added Choice 1000/300 RxDed/20/POS - 94506DC0360003 Health Insurance Plan
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. health insurance plan with the Plan ID 94506DC0360003. The plan is called KP DC Gold Added Choice 1000/300 RxDed/20/POS.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.04% (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 20.96% 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 | 94506DC0360003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | District of Columbia | ||||||||||||||||||
| Health Insurance Issuer | Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 94506DC0360003-01 | ||||||||||||||||||
| Provider Network(s) | ['DCN002'] | ||||||||||||||||||
| 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 | |||||||||||||||||||
| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
KP DC Gold Added Choice 1000/300 RxDed/20/POS Health Insurance Plan Variant 94506DC0360003-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.790443422 |
| 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 | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $300 per person | per group not applicable |
| Drug EHB Deductible, In Network (Tier 1), Individual | $300 |
| 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 |
| Disease Management Programs Offered | Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma |
| First Tier Utilization | 100% |
| Formulary ID | DCF020 |
| HIOS Product ID | 94506DC036 |
| HSA/HRA Employer Contribution | No |
| Import Date | 2/12/2024 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | Yes |
| Issuer ID | 94506 |
| 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 | $3000 per person | $6000 per group |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $3,000 |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $1000 per person | $2000 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,000 |
| Medical EHB Deductible, Out of Network, Family | $2000 per person | $4000 per group |
| Medical EHB Deductible, Out of Network, Individual | $2,000 |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | DCN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Care Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Care Only |
| Plan Effective Date | 1/1/2024 |
| Plan ID (Standard Component ID with Variant) | 94506DC0360003-01 |
| Plan Marketing Name | KP DC Gold Added Choice 1000/300 RxDed/20/POS |
| Plan Type | POS |
| Plan Variant Marketing Name | KP DC Gold Added Choice 1000/300 RxDed/20/POS |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $600 |
| SBC Scenario, Having a Baby, Deductible | $1,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $400 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $700 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | DCS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | Referrals are required for all Plan specialists with the exception of OB/GYN, Mental Health, Alcohol/Chemical Dependency, Routine Eye Exams. |
| Specialty Drug Maximum Coinsurance | $150 |
| Plan ID | 94506DC0360003 |
| State Code | DC |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family | $20250 per person | $40500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $20,250 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $6750 per person | $13500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,750 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $13500 per person | $27000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $13,500 |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of KP DC Gold Added Choice 1000/300 RxDed/20/POS Health Insurance Plan, 94506DC0360003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about KP DC Gold Added Choice 1000/300 RxDed/20/POS, 94506DC0360003 Health Insurance Plan, 94506DC0360003
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Does KP DC Gold Added Choice 1000/300 RxDed/20/POS Health Insurance Plan, 94506DC0360003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (94506DC0360003) Health Insurance Plan, Variant (94506DC0360003-01) offer Disease Management Programs?
Does (94506DC0360003) Health Insurance Plan, Variant (94506DC0360003-01) have Out Of Country Coverage?
Does (94506DC0360003) Health Insurance Plan, Variant (94506DC0360003-01) have Out of Service Area Coverage?
Does (94506DC0360003) Health Insurance Plan, Variant (94506DC0360003-01) offer Disease Management Programs?
Does KP DC Gold Added Choice 1000/300 RxDed/20/POS Health Insurance Plan, Variant (94506DC0360003-01) offer Disease Management Programs for Asthma?
Does KP DC Gold Added Choice 1000/300 RxDed/20/POS Health Insurance Plan, Variant (94506DC0360003-01) offer Disease Management Programs for Heart disease?
Does KP DC Gold Added Choice 1000/300 RxDed/20/POS Health Insurance Plan, Variant (94506DC0360003-01) offer Disease Management Programs for Depression?
Does KP DC Gold Added Choice 1000/300 RxDed/20/POS Health Insurance Plan, Variant (94506DC0360003-01) offer Disease Management Programs for Diabetes?
Does KP DC Gold Added Choice 1000/300 RxDed/20/POS Health Insurance Plan, Variant (94506DC0360003-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does KP DC Gold Added Choice 1000/300 RxDed/20/POS Health Insurance Plan, Variant (94506DC0360003-01) offer Disease Management Programs for Low back pain?
Does KP DC Gold Added Choice 1000/300 RxDed/20/POS Health Insurance Plan, Variant (94506DC0360003-01) offer Disease Management Programs for Pregnancy?
Does KP DC Gold Added Choice 1000/300 RxDed/20/POS Health Insurance Plan, Variant (94506DC0360003-01) 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