Navigator Bronze HSA 7500 - 10091OR0750002 Health Insurance Plan
PacificSource Health Plans health insurance plan with the Plan ID 10091OR0750002. The plan is called Navigator Bronze HSA 7500.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 10091OR0750002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Oregon | ||||||||||||||||||
| Health Insurance Issuer | PacificSource Health Plans | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 10091OR0750002-02 | ||||||||||||||||||
| Provider Network(s) | TIER-ONE | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 10091OR0750002-00 Standard On Exchange Plan - 10091OR0750002-01 |
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| Last Plan Update Date | Fri, 28 Jul 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 24 Dec 2024 06:21 GMT |
Benefits of Navigator Bronze HSA 7500 Health Insurance Plan, 10091OR0750002-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Accidental Dental
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Acupuncture
Limit: 12.0 Visit(s) per Year Exclusions: Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Allergy Testing
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Exclusions: Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Cosmetic Surgery
Limit: 1.0 Procedure(s) per Episode |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Dialysis
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Durable Medical Equipment
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Room Services
Exclusions: Charges for inpatient stays that began before you were covered by this plan. Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period No charge up to $150 maximum then subject to medical deductible and coinsurance. See policy for more information. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Gender Affirming Care
Information about gender affirming care can be found in plan documents. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Generic Drugs
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Visit limits do not apply to mental health conditions. See policy for more information. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Hearing Aids
Hearing assistance coverage complies with state and federal law. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Home Health Care Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Hospice Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: Charges for inpatient stays that began before you were covered by this plan. Charges for a hospital room are covered up to the hospital?s semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Inpatient Physician and Surgical Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Laboratory Outpatient and Professional Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Mental/Behavioral Health Outpatient Services
This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Non-Preferred Brand Drugs
Certain drugs may fall under a higher or lower cost sharing amount than is listed here. Insulin: $85 max out of pocket for 30 day supply prior to deductible. See policy for more information. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Nutritional Counseling
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: Missed appointments and get acquainted visits. See policy for more information. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Visit limits do not apply to mental health conditions. See policy for more information. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Preferred Brand Drugs
Certain drugs may fall under a higher or lower cost sharing amount than is listed here. Insulin: $85 max out of pocket for 30 day supply prior to deductible. See policy for more information. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Prenatal and Postnatal Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Preventive Care/Screening/Immunization
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: Missed appointments and get acquainted visits. See policy for more information. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Radiation
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Reconstructive Surgery
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Visit limits do not apply to mental health conditions. See policy for more information. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Visit limits do not apply to mental health conditions. See policy for more information. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Benefit Period Exclusions: Orthoptics, vision therapy, or other services to correct refractive error. Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. In network: Covered in Full. Out of network: No charge up to $40 maximum, and the remaining cost is member responsibility. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Routine Foot Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Year Exclusions: Confinement for custodial care is not covered. See policy for more information. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Specialist Visit
Exclusions: Missed appointments and get acquainted visits. See policy for more information. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Specialty Drugs
Certain drugs may fall under a higher or lower cost sharing amount than is listed here. $500 cap per script for Standard Gold Plans. See policy for more information. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Substance Abuse Disorder Inpatient Services
This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Substance Abuse Disorder Outpatient Services
This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Telehealth - Primary Care Visit
For services that are performed and billed as a true telemedicine visits, copays will be waived. HSA qualified plans will still be subject to the deductible and coinsurance. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Telehealth - Specialist Visit
For services that are performed and billed as a true telemedicine visits, copays will be waived. HSA qualified plans will still be subject to the deductible and coinsurance. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Transplant
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| X-rays and Diagnostic Imaging
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Navigator Bronze 7500 (0) Health Insurance Plan Variant 10091OR0750002-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 0.9999 |
| First Tier Utilization | 100% |
| Formulary ID | ORF001 |
| Formulary URL | URL |
| HIOS Product ID | 10091OR075 |
| Import Date | 2023-07-28 20:01:54 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 10091 |
| Issuer Marketplace Marketing Name | PacificSource Health Plans |
| Market Coverage | Individual |
| 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 | ORN005 |
| 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 | In and out-of-network providers |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 10091OR0750002-02 |
| Plan Marketing Name | Navigator Bronze HSA 7500 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Navigator Bronze 7500 (0) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ORS002 |
| Source Name | SERFF |
| Plan ID | 10091OR0750002 |
| State Code | OR |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| 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 | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Navigator Bronze HSA 7500 Health Insurance Plan, 10091OR0750002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Navigator Bronze HSA 7500, 10091OR0750002 Health Insurance Plan, 10091OR0750002
-
Does Navigator Bronze HSA 7500 Health Insurance Plan, 10091OR0750002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (10091OR0750002) Health Insurance Plan, Variant (10091OR0750002-02) offer Disease Management Programs?
Does (10091OR0750002) Health Insurance Plan, Variant (10091OR0750002-02) have Out Of Country Coverage?
Does (10091OR0750002) Health Insurance Plan, Variant (10091OR0750002-02) have Out of Service Area Coverage?
Does (10091OR0750002) Health Insurance Plan, Variant (10091OR0750002-02) offer Disease Management Programs?
Does Navigator Bronze 7500 (0) Health Insurance Plan, Variant (10091OR0750002-02) offer Disease Management Programs for Asthma?
Does Navigator Bronze 7500 (0) Health Insurance Plan, Variant (10091OR0750002-02) offer Disease Management Programs for Heart disease?
Does Navigator Bronze 7500 (0) Health Insurance Plan, Variant (10091OR0750002-02) offer Disease Management Programs for Diabetes?
Does Navigator Bronze 7500 (0) Health Insurance Plan, Variant (10091OR0750002-02) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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