Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified - 55584CO0030032 Health Insurance Plan
SelectHealth health insurance plan with the Plan ID 55584CO0030032. The plan is called Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.21% (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 19.79% 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 | 55584CO0030032 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Colorado | ||||||||||||||||||
| Health Insurance Issuer | SelectHealth | ||||||||||||||||||
| Health Insurance Plan Variant | 55584CO0030032-01 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| 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 | Standard On Exchange Plan - 55584CO0030032-01 |
||||||||||||||||||
| Last Plan Update Date | Fri, 31 May 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan Variant 55584CO0030032-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.802137786 |
| 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 |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 100% |
| First Tier Utilization | 100% |
| Formulary ID | COF008 |
| HIOS Product ID | 55584CO003 |
| Import Date | 5/31/2024 |
| HSA Eligible | Yes |
| IsItANewPlan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 55584 |
| Market Coverage | Individual |
| 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 | CON001 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Urgent / Emergent Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Urgent / Emergent Only |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 55584CO0030032-01 |
| Plan Level Exclusions | Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Administrative Services/Charges; Certain Allergy Tests; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses; computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items. |
| Plan Marketing Name | Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified |
| Plan Type | EPO |
| Plan Variant Marketing Name | Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,000 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $1,750 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $60 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $1,750 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $30 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,750 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | COS002 |
| Source Name | SERFF |
| Plan ID | 55584CO0030032 |
| State Code | CO |
| 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 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group 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 | 10.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $3500 per person | $3500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,750 |
| 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 | $8050 per person | $16100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,050 |
| 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 | No |
Copay & Coinsurance of Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan, 55584CO0030032
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified, 55584CO0030032 Health Insurance Plan, 55584CO0030032
-
Does Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan, 55584CO0030032 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (55584CO0030032) Health Insurance Plan, Variant (55584CO0030032-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma
Does (55584CO0030032) Health Insurance Plan, Variant (55584CO0030032-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan). Details: Urgent / Emergent Only
Does (55584CO0030032) Health Insurance Plan, Variant (55584CO0030032-01) have Out of Service Area Coverage?
Yes. Details: Urgent / Emergent Only
Does (55584CO0030032) Health Insurance Plan, Variant (55584CO0030032-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma
Does Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan, Variant (55584CO0030032-01) offer Disease Management Programs for Asthma?
Yes, the Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan Variant
55584CO0030032-01 offers Disease
Management Program for Asthma.
Does Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan, Variant (55584CO0030032-01) offer Disease Management Programs for Heart disease?
Yes, the Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan Variant
55584CO0030032-01 offers Disease
Management Program for Heart disease.
Does Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan, Variant (55584CO0030032-01) offer Disease Management Programs for Depression?
Yes, the Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan Variant
55584CO0030032-01 offers Disease
Management Program for Depression.
Does Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan, Variant (55584CO0030032-01) offer Disease Management Programs for Diabetes?
Yes, the Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan Variant
55584CO0030032-01 offers Disease
Management Program for Diabetes.
Does Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan, Variant (55584CO0030032-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan Variant
55584CO0030032-01 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan, Variant (55584CO0030032-01) offer Disease Management Programs for Low back pain?
Yes, the Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan Variant
55584CO0030032-01 offers Disease
Management Program for Low back pain.
Does Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan, Variant (55584CO0030032-01) offer Disease Management Programs for Pregnancy?
Yes, the Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan Variant
55584CO0030032-01 offers Disease
Management Program for Pregnancy.
Does Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan, Variant (55584CO0030032-01) offer Disease Management Programs for Weight loss programs?
Yes, the Select Health Monument Value Gold $1750 Medical Deductible HSA Qualified Health Insurance Plan Variant
55584CO0030032-01 offers Disease
Management Program 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