MTRO GT 25/40/1250/80 EPO 24 GOLD NS INN DEP 25 DP FP - 85629NY0010471 Health Insurance Plan
Oxford Health Insurance, Inc. health insurance plan with the Plan ID 85629NY0010471. The plan is called MTRO GT 25/40/1250/80 EPO 24 GOLD NS INN DEP 25 DP FP.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 80.73% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.27% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 85629NY0010471 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | Oxford Health Insurance, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 85629NY0010471-01 | ||||||||||||||||||
| 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). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 10 Dec 2024 06:32 GMT |
MTRO GT 25/40/1250/80 EPO 24 GOLD NS INN DEP 25 DP FP Health Insurance Plan Variant 85629NY0010471-01 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 | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $150 per person | per group not applicable |
| Drug EHB Deductible, In Network (Tier 1), Individual | $150 |
| 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, Diabetes, Heart Disease |
| First Tier Utilization | 100% |
| Formulary ID | NYF005 |
| HIOS Product ID | 85629NY001 |
| HSA/HRA Employer Contribution | No |
| Import Date | 2/12/2024 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 80.73% |
| Issuer ID | 85629 |
| 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 | 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 | $1250 per person | $2500 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,250 |
| 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 | Yes |
| 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) | 85629NY0010471-01 |
| Plan Marketing Name | MTRO GT 25/40/1250/80 EPO 24 GOLD NS INN DEP 25 DP FP |
| Plan Type | EPO |
| Plan Variant Marketing Name | MTRO GT 25/40/1250/80 EPO 24 GOLD NS INN DEP 25 DP FP |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,300 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $1,250 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $10 |
| SBC Scenario, Having Diabetes, Copayment | $200 |
| SBC Scenario, Having Diabetes, Deductible | $1,250 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $10 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $700 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,250 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NYS002 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All, except OBGYN and as state mandated |
| Plan ID | 85629NY0010471 |
| State Code | NY |
| 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 | $6500 per person | $13000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,500 |
| 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 MTRO GT 25/40/1250/80 EPO 24 GOLD NS INN DEP 25 DP FP Health Insurance Plan, 85629NY0010471
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about MTRO GT 25/40/1250/80 EPO 24 GOLD NS INN DEP 25 DP FP, 85629NY0010471 Health Insurance Plan, 85629NY0010471
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Does MTRO GT 25/40/1250/80 EPO 24 GOLD NS INN DEP 25 DP FP Health Insurance Plan, 85629NY0010471 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (85629NY0010471) Health Insurance Plan, Variant (85629NY0010471-01) offer Disease Management Programs?
Does (85629NY0010471) Health Insurance Plan, Variant (85629NY0010471-01) have Out Of Country Coverage?
Does (85629NY0010471) Health Insurance Plan, Variant (85629NY0010471-01) have Out of Service Area Coverage?
Does (85629NY0010471) Health Insurance Plan, Variant (85629NY0010471-01) offer Disease Management Programs?
Does MTRO GT 25/40/1250/80 EPO 24 GOLD NS INN DEP 25 DP FP Health Insurance Plan, Variant (85629NY0010471-01) offer Disease Management Programs for Heart disease?
Does MTRO GT 25/40/1250/80 EPO 24 GOLD NS INN DEP 25 DP FP Health Insurance Plan, Variant (85629NY0010471-01) offer Disease Management Programs for Diabetes?
Does MTRO GT 25/40/1250/80 EPO 24 GOLD NS INN DEP 25 DP FP Health Insurance Plan, Variant (85629NY0010471-01) offer Disease Management Programs for Pregnancy?
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