SelectHealth health insurance plan with the Plan ID 26002ID0010051. The plan is called SelectHealth SAHA Silver 4000 - $0 copay for PCP visits.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.69% (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 12.31% 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 | 26002ID0010051 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Idaho | ||||||||||||||||||
Health Insurance Issuer | SelectHealth | ||||||||||||||||||
Health Insurance Plan Variant | 26002ID0010051-05 | ||||||||||||||||||
Provider Network(s) | ['IDN003'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 GMT). |
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Available Variants of the Health Plan | Standard On Exchange Plan - 26002ID0010051-01 Open to Indians below 300% FPL - 26002ID0010051-02 Open to Indians above 300% FPL - 26002ID0010051-03 73% AV Silver Plan - 26002ID0010051-04 |
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Last Plan Update Date | Mon, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Plan Attribute | Value |
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AV Calculator Output Number | 0.876928243 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | 87% AV Level Silver Plan |
Drug EHB Deductible, Combined In/Out of Network, Family | $250 per person | per group not applicable |
Drug EHB Deductible, Combined In/Out of Network, Individual | $250 |
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 | Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol |
EHB Percent of Total Premium | 100% |
First Tier Utilization | 100% |
Formulary ID | IDF008 |
HIOS Product ID | 26002ID001 |
Import Date | 1/23/2023 |
HSA Eligible | No |
IsItANewPlan | New |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
Issuer ID | 26002 |
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 | $700 per person | $1400 per group |
Medical EHB Deductible, In Network (Tier 1), Individual | $700 |
Medical EHB Deductible, Out of Network, Family | $18200 per person | $36400 per group |
Medical EHB Deductible, Out of Network, Individual | $18,200 |
Metal Level | Silver |
Multiple In Network Tiers | No |
National Network | Yes |
Network ID | IDN003 |
Out of Country Coverage | No |
Out of Service Area Coverage | No |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 26002ID0010051-05 |
Plan Level Exclusions | Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; 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 where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; 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 | SelectHealth SAHA Silver 4000 - $0 copay for PCP visits |
Plan Type | PPO |
Plan Variant Marketing Name | SelectHealth SAHA Silver 4000 - $0 copay for PCP visits |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $2,000 |
SBC Scenario, Having a Baby, Copayment | $300 |
SBC Scenario, Having a Baby, Deductible | $700 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $30 |
SBC Scenario, Having Diabetes, Copayment | $200 |
SBC Scenario, Having Diabetes, Deductible | $700 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $900 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $700 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | IDS003 |
Source Name | SERFF |
Plan ID | 26002ID0010051 |
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 | $3000 per person | $6000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,000 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $91000 per person | $182000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $91,000 |
Unique Plan Design | No |
Version Number | 1 |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 20 Aug 2024 06:14 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