Navigator Silver HSA 3500 - 23603MT0290002 Health Insurance Plan
PacificSource Health Plans health insurance plan with the Plan ID 23603MT0290002. The plan is called Navigator Silver HSA 3500.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.47% (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 29.53% 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 | 23603MT0290002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Montana | ||||||||||||||||||
| Health Insurance Issuer | PacificSource Health Plans | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 23603MT0290002-01 | ||||||||||||||||||
| Provider Network(s) | TIER-ONE | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 23603MT0290002-00 Standard On Exchange Plan - 23603MT0290002-01 Open to Indians below 300% FPL - 23603MT0290002-02 Open to Indians above 300% FPL - 23603MT0290002-03 73% AV Silver Plan - 23603MT0290002-04 |
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| Last Plan Update Date | Fri, 13 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Navigator Silver HSA 3500 Health Insurance Plan, 23603MT0290002-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Allergy Testing
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 10.0 Visit(s) per Benefit Period Exclusions: Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
Limit: 1.0 Procedure(s) per Episode Exclusions: Cosmetic surgery (except in certain situations). See policy for more information. Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
Exclusions: The benefit does not cover further treatment provided on referral from the emergency room. For emergency medical conditions, out-of-network providers are paid at the in-network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance. |
YES | No Charge, 25.00% Coinsurance after deductible |
No Charge, 25.00% Coinsurance after deductible |
| Gender Affirming Care
Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary. |
NO | ||
| Generic Drugs
Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Habilitation Services
See policy for more information. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Hearing Aids
The diagnosis and treatment of hearing loss and one amplification device for each ear every three years as required be an audiologist for members age 18 and younger. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Home Health Care Services
Limit: 180.0 Visit(s) per Benefit Period Exclusions: Private duty nursing not covered Covered services include services by licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Hospice Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
Exclusions: Services and supplies for in vitro fertilization, erectile dysfunction, sexual dysfunction, or surgery to reverse voluntary sterilization. Services provided by out-of-network providers are not covered. Treatment includes services to diagnose infertility, services related to artificial insemination. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 an regulations related to the Mental Health Parity and Addiction Equity Act of 2008. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
This health plan complies with all federal laws an regulations related to the Mental Health Parity and Addiction Equity Act of 2008. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Nutritional Counseling
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
See policy for more information. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Prenatal and Postnatal Care
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
25.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: Missed appointments and get acquainted visits. See policy for more information. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
Exclusions: Private duty nurse not covered. |
NO | ||
| Prosthetic Devices
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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. When using an in-network provider eye exams are covered in full. When using an out-of-network provider the first $40 is covered and the remaining cost is member responsibility. |
YES | No Charge |
No Charge |
| Routine Foot Care
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period Exclusions: Confinement or custodial care is not covered. See policy for more information. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
Exclusions: Missed appointments and get acquainted visits. See policy for more information. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Specialty Drugs
Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Transplant
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
25.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Navigator Silver HSA 3500 Health Insurance Plan Variant 23603MT0290002-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7046691542667858 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | MTF003 |
| Formulary URL | URL |
| HIOS Product ID | 23603MT029 |
| Import Date | 2024-09-13 20:01:37 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 23603 |
| 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 | Silver |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | MTN003 |
| 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 | Non-Participating Providers |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 23603MT0290002-01 |
| Plan Marketing Name | Navigator Silver HSA 3500 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Navigator Silver HSA 3500 |
| 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 | $3,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $500 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $3,500 |
| 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 | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MTS001 |
| Source Name | SERFF |
| Plan ID | 23603MT0290002 |
| State Code | MT |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $7000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $60000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $30000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $30,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $13400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,700 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $73600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $36800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $36,800 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Navigator Silver HSA 3500 Health Insurance Plan, 23603MT0290002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Navigator Silver HSA 3500, 23603MT0290002 Health Insurance Plan, 23603MT0290002
-
Does Navigator Silver HSA 3500 Health Insurance Plan, 23603MT0290002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (23603MT0290002) Health Insurance Plan, Variant (23603MT0290002-01) offer Disease Management Programs?
Does (23603MT0290002) Health Insurance Plan, Variant (23603MT0290002-01) have Out Of Country Coverage?
Does (23603MT0290002) Health Insurance Plan, Variant (23603MT0290002-01) have Out of Service Area Coverage?
Does (23603MT0290002) Health Insurance Plan, Variant (23603MT0290002-01) offer Disease Management Programs?
Does Navigator Silver HSA 3500 Health Insurance Plan, Variant (23603MT0290002-01) offer Disease Management Programs for Asthma?
Does Navigator Silver HSA 3500 Health Insurance Plan, Variant (23603MT0290002-01) offer Disease Management Programs for Heart disease?
Does Navigator Silver HSA 3500 Health Insurance Plan, Variant (23603MT0290002-01) offer Disease Management Programs for Diabetes?
Does Navigator Silver HSA 3500 Health Insurance Plan, Variant (23603MT0290002-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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