MTRO GT 35/50/4000/70 EPO HSA 24 SILVER NS INN DEP 29 - 85629NY0010491 Health Insurance Plan
Oxford Health Insurance, Inc. health insurance plan with the Plan ID 85629NY0010491. The plan is called MTRO GT 35/50/4000/70 EPO HSA 24 SILVER NS INN DEP 29 .
Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.99% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.01% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 85629NY0010491 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | Oxford Health Insurance, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 85629NY0010491-01 | ||||||||||||||||||
| 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 35/50/4000/70 EPO HSA 24 SILVER NS INN DEP 29 Health Insurance Plan Variant 85629NY0010491-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver On Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Pregnancy, Diabetes, Heart Disease |
| First Tier Utilization | 100% |
| Formulary ID | NYF001 |
| HIOS Product ID | 85629NY001 |
| HSA/HRA Employer Contribution | Yes |
| HSA/HRA Employer Contribution Amount | $270.00 |
| Import Date | 2/12/2024 |
| HSA Eligible | Yes |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 71.99% |
| Issuer ID | 85629 |
| Market Coverage | SHOP (Small Group) |
| 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 | 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) | 85629NY0010491-01 |
| Plan Marketing Name | MTRO GT 35/50/4000/70 EPO HSA 24 SILVER NS INN DEP 29 |
| Plan Type | EPO |
| Plan Variant Marketing Name | MTRO GT 35/50/4000/70 EPO HSA 24 SILVER NS INN DEP 29 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,100 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $4,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $100 |
| SBC Scenario, Having Diabetes, Deductible | $4,000 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| 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 |
| Specialty Drug Maximum Coinsurance | $800 |
| Plan ID | 85629NY0010491 |
| 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 |
| 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 | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $8000 per person | $8000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,000 |
| 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 | $7200 per person | $14400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,200 |
| 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 35/50/4000/70 EPO HSA 24 SILVER NS INN DEP 29 Health Insurance Plan, 85629NY0010491
| 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 35/50/4000/70 EPO HSA 24 SILVER NS INN DEP 29 , 85629NY0010491 Health Insurance Plan, 85629NY0010491
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Does MTRO GT 35/50/4000/70 EPO HSA 24 SILVER NS INN DEP 29 Health Insurance Plan, 85629NY0010491 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (85629NY0010491) Health Insurance Plan, Variant (85629NY0010491-01) offer Disease Management Programs?
Does (85629NY0010491) Health Insurance Plan, Variant (85629NY0010491-01) have Out Of Country Coverage?
Does (85629NY0010491) Health Insurance Plan, Variant (85629NY0010491-01) have Out of Service Area Coverage?
Does (85629NY0010491) Health Insurance Plan, Variant (85629NY0010491-01) offer Disease Management Programs?
Does MTRO GT 35/50/4000/70 EPO HSA 24 SILVER NS INN DEP 29 Health Insurance Plan, Variant (85629NY0010491-01) offer Disease Management Programs for Heart disease?
Does MTRO GT 35/50/4000/70 EPO HSA 24 SILVER NS INN DEP 29 Health Insurance Plan, Variant (85629NY0010491-01) offer Disease Management Programs for Diabetes?
Does MTRO GT 35/50/4000/70 EPO HSA 24 SILVER NS INN DEP 29 Health Insurance Plan, Variant (85629NY0010491-01) 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