Select HMO 2000 25/60 II - 41304MA0142052 Health Insurance Plan
Mass General Brigham Health Plan health insurance plan with the Plan ID 41304MA0142052. The plan is called Select HMO 2000 25/60 II.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 94.85% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 5.15% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 41304MA0142052 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Massachusetts | ||||||||||||||||||
| Health Insurance Issuer | Mass General Brigham Health Plan | ||||||||||||||||||
| Health Insurance Plan Variant | 41304MA0142052-06 | ||||||||||||||||||
| Provider Network(s) | ['MAN003'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 26 Nov 2024 06:27 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 41304MA0142052-01 Open to Indians below 300% FPL - 41304MA0142052-02 Open to Indians above 300% FPL - 41304MA0142052-03 73% AV Silver Plan - 41304MA0142052-04 |
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| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 26 Nov 2024 06:27 GMT |
Mass General Brigham Health Plan Select ConnectorCare 1 Health Insurance Plan Variant 41304MA0142052-06 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | 94% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Pregnancy, Weight Loss Programs, Pain Management, Depression, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 99% |
| First Tier Utilization | 100% |
| Formulary ID | MAF004 |
| HIOS Product ID | 41304MA014 |
| 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 | 94.85% |
| Issuer ID | 41304 |
| 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 | No |
| Network ID | MAN003 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Urgent and Emergency only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Urgent and Emergency only |
| Plan Effective Date | 1/1/2024 |
| Plan ID (Standard Component ID with Variant) | 41304MA0142052-06 |
| Plan Marketing Name | Select HMO 2000 25/60 II |
| Plan Type | HMO |
| Plan Variant Marketing Name | Mass General Brigham Health Plan Select ConnectorCare 1 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $7 |
| 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 | $50 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MAS002 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All except: Gynecologist or Obstetrician for routine, preventive or urgent care; Family Planning services; Outpatient and Diversionary Behavioral Health Services; Routine Eye Exam; Physical Therapy; Occupational Therapy; Speech Therapy and Emergency Services. |
| Plan ID | 41304MA0142052 |
| State Code | MA |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | $250 per person | $500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $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 | Yes |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Select HMO 2000 25/60 II Health Insurance Plan, 41304MA0142052
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Select HMO 2000 25/60 II, 41304MA0142052 Health Insurance Plan, 41304MA0142052
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Does Select HMO 2000 25/60 II Health Insurance Plan, 41304MA0142052 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (41304MA0142052) Health Insurance Plan, Variant (41304MA0142052-06) offer Disease Management Programs?
Does (41304MA0142052) Health Insurance Plan, Variant (41304MA0142052-06) have Out Of Country Coverage?
Does (41304MA0142052) Health Insurance Plan, Variant (41304MA0142052-06) have Out of Service Area Coverage?
Does (41304MA0142052) Health Insurance Plan, Variant (41304MA0142052-06) offer Disease Management Programs?
Does Mass General Brigham Health Plan Select ConnectorCare 1 Health Insurance Plan, Variant (41304MA0142052-06) offer Disease Management Programs for Asthma?
Does Mass General Brigham Health Plan Select ConnectorCare 1 Health Insurance Plan, Variant (41304MA0142052-06) offer Disease Management Programs for Heart disease?
Does Mass General Brigham Health Plan Select ConnectorCare 1 Health Insurance Plan, Variant (41304MA0142052-06) offer Disease Management Programs for Depression?
Does Mass General Brigham Health Plan Select ConnectorCare 1 Health Insurance Plan, Variant (41304MA0142052-06) offer Disease Management Programs for Diabetes?
Does Mass General Brigham Health Plan Select ConnectorCare 1 Health Insurance Plan, Variant (41304MA0142052-06) offer Disease Management Programs for Pregnancy?
Does Mass General Brigham Health Plan Select ConnectorCare 1 Health Insurance Plan, Variant (41304MA0142052-06) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 26 Nov 2024 06:27 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