PQA Southeast Silver Copay Connect 3500 - 61589ID2360139 Health Insurance Plan
Blue Cross of Idaho Health Service, Inc. health insurance plan with the Plan ID 61589ID2360139. The plan is called PQA Southeast Silver Copay Connect 3500.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 94.46% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 5.54% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 93.86% (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 6.14% 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 | 61589ID2360139 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Idaho | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross of Idaho Health Service, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 61589ID2360139-06 | ||||||||||||||||||
| Provider Network(s) | ['IDN006'] | ||||||||||||||||||
| 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 On Exchange Plan - 61589ID2360139-01 Open to Indians below 300% FPL - 61589ID2360139-02 Open to Indians above 300% FPL - 61589ID2360139-03 73% AV Silver Plan - 61589ID2360139-04 |
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| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
PQA Southeast Silver Copay Connect 3500 CSR 94 Health Insurance Plan Variant 61589ID2360139-06 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.938607289 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | 94% AV Level Silver Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family | $0 per person | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| 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 |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 100% |
| First Tier Utilization | 100% |
| Formulary ID | IDF002 |
| HIOS Product ID | 61589ID236 |
| 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 | 94.46% |
| Issuer ID | 61589 |
| Market Coverage | Individual |
| 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 | 30.00% |
| 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 | $18900 per person | $37800 per group |
| Medical EHB Deductible, Out of Network, Individual | $18,900 |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | IDN006 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 61589ID2360139-06 |
| Plan Marketing Name | PQA Southeast Silver Copay Connect 3500 |
| Plan Type | POS |
| Plan Variant Marketing Name | PQA Southeast Silver Copay Connect 3500 CSR 94 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,160 |
| SBC Scenario, Having a Baby, Copayment | $240 |
| 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 | $680 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $380 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | IDS007 |
| Source Name | SERFF |
| Specialist Requiring a Referral | Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery |
| Plan ID | 61589ID2360139 |
| State Code | ID |
| 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 | $1400 per person | $2800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $1,400 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $94500 per person | $189000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $94,500 |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of PQA Southeast Silver Copay Connect 3500 Health Insurance Plan, 61589ID2360139
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about PQA Southeast Silver Copay Connect 3500, 61589ID2360139 Health Insurance Plan, 61589ID2360139
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Does PQA Southeast Silver Copay Connect 3500 Health Insurance Plan, 61589ID2360139 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (61589ID2360139) Health Insurance Plan, Variant (61589ID2360139-06) offer Disease Management Programs?
Does (61589ID2360139) Health Insurance Plan, Variant (61589ID2360139-06) have Out Of Country Coverage?
Does (61589ID2360139) Health Insurance Plan, Variant (61589ID2360139-06) have Out of Service Area Coverage?
Does (61589ID2360139) Health Insurance Plan, Variant (61589ID2360139-06) offer Disease Management Programs?
Does PQA Southeast Silver Copay Connect 3500 CSR 94 Health Insurance Plan, Variant (61589ID2360139-06) offer Disease Management Programs for Asthma?
Does PQA Southeast Silver Copay Connect 3500 CSR 94 Health Insurance Plan, Variant (61589ID2360139-06) offer Disease Management Programs for Heart disease?
Does PQA Southeast Silver Copay Connect 3500 CSR 94 Health Insurance Plan, Variant (61589ID2360139-06) offer Disease Management Programs for Diabetes?
Does PQA Southeast Silver Copay Connect 3500 CSR 94 Health Insurance Plan, Variant (61589ID2360139-06) offer Disease Management Programs for High blood pressure & high cholesterol?
Does PQA Southeast Silver Copay Connect 3500 CSR 94 Health Insurance Plan, Variant (61589ID2360139-06) offer Disease Management Programs for Pregnancy?
Does PQA Southeast Silver Copay Connect 3500 CSR 94 Health Insurance Plan, Variant (61589ID2360139-06) offer Disease Management Programs for Weight loss programs?
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