Non-Standard Low Gold: WellSense Clarity Gold1500SG - 82569MA0490001 Health Insurance Plan
WellSense Health Plan health insurance plan with the Plan ID 82569MA0490001. The plan is called Non-Standard Low Gold: WellSense Clarity Gold1500SG.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.10% (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 21.90% 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 | 82569MA0490001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Massachusetts | ||||||||||||||||||
| Health Insurance Issuer | WellSense Health Plan | ||||||||||||||||||
| Health Insurance Plan Variant | 82569MA0490001-01 | ||||||||||||||||||
| Provider Network(s) | ['MAN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Non-Standard Low Gold: WellSense Clarity Gold1500SG Health Insurance Plan Variant 82569MA0490001-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.781 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Pregnancy, High Blood Pressure & High Cholesterol, Depression, Asthma |
| First Tier Utilization | 100% |
| Formulary ID | MAF003 |
| HIOS Product ID | 82569MA049 |
| 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? | No |
| Issuer ID | 82569 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MAN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency and Urgent Care Only |
| Plan Effective Date | 1/1/2024 |
| Plan ID (Standard Component ID with Variant) | 82569MA0490001-01 |
| Plan Marketing Name | Non-Standard Low Gold: WellSense Clarity Gold1500SG |
| Plan Type | HMO |
| Plan Variant Marketing Name | Non-Standard Low Gold: WellSense Clarity Gold1500SG |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $750 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $70 |
| SBC Scenario, Having Diabetes, Copayment | $800 |
| SBC Scenario, Having Diabetes, Deductible | $1,500 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MAS001 |
| Source Name | SERFF |
| Plan ID | 82569MA0490001 |
| State Code | MA |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family | $5250 per person | $10500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $5,250 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family | $1500 per person | $3000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 100.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $1500 per person | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| 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 | $5250 per person | $10500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,250 |
| 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 | No |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Non-Standard Low Gold: WellSense Clarity Gold1500SG Health Insurance Plan, 82569MA0490001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Non-Standard Low Gold: WellSense Clarity Gold1500SG, 82569MA0490001 Health Insurance Plan, 82569MA0490001
-
Does Non-Standard Low Gold: WellSense Clarity Gold1500SG Health Insurance Plan, 82569MA0490001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (82569MA0490001) Health Insurance Plan, Variant (82569MA0490001-01) offer Disease Management Programs?
Does (82569MA0490001) Health Insurance Plan, Variant (82569MA0490001-01) have Out Of Country Coverage?
Does (82569MA0490001) Health Insurance Plan, Variant (82569MA0490001-01) have Out of Service Area Coverage?
Does (82569MA0490001) Health Insurance Plan, Variant (82569MA0490001-01) offer Disease Management Programs?
Does Non-Standard Low Gold: WellSense Clarity Gold1500SG Health Insurance Plan, Variant (82569MA0490001-01) offer Disease Management Programs for Asthma?
Does Non-Standard Low Gold: WellSense Clarity Gold1500SG Health Insurance Plan, Variant (82569MA0490001-01) offer Disease Management Programs for Depression?
Does Non-Standard Low Gold: WellSense Clarity Gold1500SG Health Insurance Plan, Variant (82569MA0490001-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Non-Standard Low Gold: WellSense Clarity Gold1500SG Health Insurance Plan, Variant (82569MA0490001-01) 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