Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. health insurance plan with the Plan ID 95185VA0500012. The plan is called KP VA Bronze 6500/50/Vision.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.55% (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 35.45% 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 | 95185VA0500012 | ||||||||||||||||||
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Health Insurance Plan Year | 2022 | ||||||||||||||||||
State | Virginia | ||||||||||||||||||
Health Insurance Issuer | Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 95185VA0500012-00 | ||||||||||||||||||
Provider Network(s) | ['VAN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 01 Oct 2024 06:11 GMT). |
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Available Variants of the Health Plan | |||||||||||||||||||
Last Plan Update Date | Fri, 18 Mar 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 01 Oct 2024 06:11 GMT |
Plan Attribute | Value |
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AV Calculator Output Number | 0.645471147 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2022 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Bronze Off Exchange Plan |
Dental Only Plan | No |
Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
First Tier Utilization | 100% |
Formulary ID | VAF010 |
Formulary URL | URL |
HIOS Product ID | 95185VA050 |
HSA/HRA Employer Contribution | No |
Import Date | 3/18/2022 20:01 |
Inpatient Copayment Maximum Days | 5 |
HSA Eligible | No |
New/Existing Plan | Existing |
Notice Required for Pregnancy | Yes |
Is a Referral Required for Specialist? | Yes |
Issuer ID | 95185 |
Issuer Marketplace Marketing Name | Kaiser Permanente |
Market Coverage | SHOP (Small Group) |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Expanded Bronze |
Multiple In Network Tiers | No |
National Network | No |
Network ID | VAN001 |
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 | 1/1/2022 |
Plan ID (Standard Component ID with Variant) | 95185VA0500012-00 |
Plan Marketing Name | KP VA Bronze 6500/50/Vision |
Plan Type | HMO |
Plan Variant Marketing Name | KP VA Bronze 6500/50/Vision |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $500 |
SBC Scenario, Having a Baby, Deductible | $6,500 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $500 |
SBC Scenario, Having Diabetes, Deductible | $3,500 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | VAS001 |
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 | $300 |
Plan ID | 95185VA0500012 |
State Code | VA |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person 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 Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person 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 | 0.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $13000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6500 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,500 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person 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 Per Group | $17400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
Unique Plan Design | No |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
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, 01 Oct 2024 06:11 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