PPO Copay/Coinsurance 131, Platinum, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP - 92551NY0390071 Health Insurance Plan
CDPHP Universal Benefits, Inc. health insurance plan with the Plan ID 92551NY0390071. The plan is called PPO Copay/Coinsurance 131, Platinum, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 89.20% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 10.80% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 92551NY0390071 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | CDPHP Universal Benefits, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 92551NY0390071-01 | ||||||||||||||||||
| Provider Network(s) | ['NYN003'] | ||||||||||||||||||
| 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 |
PPO Copay/Coinsurance 131, Platinum, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP Health Insurance Plan Variant 92551NY0390071-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2024 |
| Child-Only Offering | Allows Adult-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Platinum On Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, In Network (Tier 1), Individual | Not Applicable |
| Drug EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| First Tier Utilization | 100% |
| Formulary ID | NYF006 |
| HIOS Product ID | 92551NY039 |
| 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? | Yes |
| Issuer Actuarial Value | 89.20% |
| Issuer ID | 92551 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family | $6000 per person | $12000 per group |
| Medical EHB Deductible, Out of Network, Individual | $6,000 |
| Metal Level | Platinum |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | NYN003 |
| 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) | 92551NY0390071-01 |
| Plan Marketing Name | PPO Copay/Coinsurance 131, Platinum, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP |
| Plan Type | PPO |
| Plan Variant Marketing Name | PPO Copay/Coinsurance 131, Platinum, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $816 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,096 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $37 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $375 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $212 |
| Service Area ID | NYS002 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All |
| Plan ID | 92551NY0390071 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $6000 per person | $12000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $12000 per person | $24000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $12,000 |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of PPO Copay/Coinsurance 131, Platinum, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP Health Insurance Plan, 92551NY0390071
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about PPO Copay/Coinsurance 131, Platinum, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP, 92551NY0390071 Health Insurance Plan, 92551NY0390071
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Does PPO Copay/Coinsurance 131, Platinum, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP Health Insurance Plan, 92551NY0390071 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (92551NY0390071) Health Insurance Plan, Variant (92551NY0390071-01) have Out Of Country Coverage?
Does (92551NY0390071) Health Insurance Plan, Variant (92551NY0390071-01) have Out of Service Area Coverage?
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