MTRO GT 7250/100 EPO HSA 24 BRONZE NS INN DEP 29 DP - 85629NY0010604 Health Insurance Plan

Oxford Health Insurance, Inc. health insurance plan with the Plan ID 85629NY0010604. The plan is called MTRO GT 7250/100 EPO HSA 24 BRONZE NS INN DEP 29 DP.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.64% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.36% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 85629NY0010604
Health Insurance Plan Year 2024
State New York
Health Insurance Issuer Oxford Health Insurance, Inc.
Health Insurance Plan Variant 85629NY0010604-01
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).

Providers New York All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard On Exchange Plan - 85629NY0010604-01

Last Plan Update Date Mon, 12 Feb 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

MTRO GT 7250/100 EPO HSA 24 BRONZE NS INN DEP 29 DP Health Insurance Plan Variant 85629NY0010604-01 Attributes

Plan Attribute Value
Business Year 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze On Exchange Plan
Dental Only Plan No
Disease Management Programs Offered Pregnancy, Diabetes, Heart Disease
First Tier Utilization 100%
Formulary ID NYF003
HIOS Product ID 85629NY001
HSA/HRA Employer Contribution No
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 64.64%
Issuer ID 85629
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 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) 85629NY0010604-01
Plan Marketing Name MTRO GT 7250/100 EPO HSA 24 BRONZE NS INN DEP 29 DP
Plan Type EPO
Plan Variant Marketing Name MTRO GT 7250/100 EPO HSA 24 BRONZE NS INN DEP 29 DP
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $7,250
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $5,400
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
Plan ID 85629NY0010604
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 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family $14500 per person | $14500 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,250
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 $7250 per person | $14500 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,250
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 7250/100 EPO HSA 24 BRONZE NS INN DEP 29 DP Health Insurance Plan, 85629NY0010604

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about MTRO GT 7250/100 EPO HSA 24 BRONZE NS INN DEP 29 DP, 85629NY0010604 Health Insurance Plan, 85629NY0010604

  • Does MTRO GT 7250/100 EPO HSA 24 BRONZE NS INN DEP 29 DP Health Insurance Plan, 85629NY0010604 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

    • Does (85629NY0010604) Health Insurance Plan, Variant (85629NY0010604-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Pregnancy, Diabetes, Heart Disease

    Does (85629NY0010604) Health Insurance Plan, Variant (85629NY0010604-01) have Out Of Country Coverage?

    Yes. Details: Emergency Only

    Does (85629NY0010604) Health Insurance Plan, Variant (85629NY0010604-01) have Out of Service Area Coverage?

    Yes. Details: Emergency Only

    Does (85629NY0010604) Health Insurance Plan, Variant (85629NY0010604-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Pregnancy, Diabetes, Heart Disease

    Does MTRO GT 7250/100 EPO HSA 24 BRONZE NS INN DEP 29 DP Health Insurance Plan, Variant (85629NY0010604-01) offer Disease Management Programs for Heart disease?

    Yes, the MTRO GT 7250/100 EPO HSA 24 BRONZE NS INN DEP 29 DP Health Insurance Plan Variant 85629NY0010604-01 offers Disease Management Program for Heart disease.

    Does MTRO GT 7250/100 EPO HSA 24 BRONZE NS INN DEP 29 DP Health Insurance Plan, Variant (85629NY0010604-01) offer Disease Management Programs for Diabetes?

    Yes, the MTRO GT 7250/100 EPO HSA 24 BRONZE NS INN DEP 29 DP Health Insurance Plan Variant 85629NY0010604-01 offers Disease Management Program for Diabetes.

    Does MTRO GT 7250/100 EPO HSA 24 BRONZE NS INN DEP 29 DP Health Insurance Plan, Variant (85629NY0010604-01) offer Disease Management Programs for Pregnancy?

    Yes, the MTRO GT 7250/100 EPO HSA 24 BRONZE NS INN DEP 29 DP Health Insurance Plan Variant 85629NY0010604-01 offers Disease Management Program 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