Silver 70 Ambetter PPO - 67138CA0700013 Health Insurance Plan
Health Net of California health insurance plan with the Plan ID 67138CA0700013. The plan is called Silver 70 Ambetter PPO.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 74.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 26.00% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 67138CA0700013 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | California | ||||||||||||||||||
| Health Insurance Issuer | Health Net of California | ||||||||||||||||||
| Health Insurance Plan Variant | 67138CA0700013-04 | ||||||||||||||||||
| Provider Network(s) | ['CAN003'] | ||||||||||||||||||
| 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 - 67138CA0700013-01 Open to Indians below 300% FPL - 67138CA0700013-02 Open to Indians above 300% FPL - 67138CA0700013-03 73% AV Silver Plan - 67138CA0700013-04 |
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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 |
Silver 73 Ambetter PPO Health Insurance Plan Variant 67138CA0700013-04 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | 73% AV Level Silver 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 | 30.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 |
| EHB Percent of Total Premium | 99% |
| First Tier Utilization | 100% |
| Formulary ID | CAF003 |
| HIOS Product ID | 67138CA070 |
| Import Date | 2/12/2024 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 74.00% |
| Issuer ID | 67138 |
| 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 | $9500 per person | $19000 per group |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $9,500 |
| 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 | $9500 per person | $19000 per group |
| Medical EHB Deductible, Out of Network, Individual | $9,500 |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | CAN003 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Effective Date | 1/1/2024 |
| Plan ID (Standard Component ID with Variant) | 67138CA0700013-04 |
| Plan Marketing Name | Silver 70 Ambetter PPO |
| Plan Type | PPO |
| Plan Variant Marketing Name | Silver 73 Ambetter PPO |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $2,500 |
| SBC Scenario, Having a Baby, Copayment | $800 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $200 |
| SBC Scenario, Having Diabetes, Copayment | $1,400 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | CAS001 |
| Source Name | SERFF |
| Specialty Drug Maximum Coinsurance | $250 |
| Plan ID | 67138CA0700013 |
| State Code | CA |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family | $31100 per person | $62200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $31,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $6100 per person | $12200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $25000 per person | $50000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $25,000 |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Silver 70 Ambetter PPO Health Insurance Plan, 67138CA0700013
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Silver 70 Ambetter PPO, 67138CA0700013 Health Insurance Plan, 67138CA0700013
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Does Silver 70 Ambetter PPO Health Insurance Plan, 67138CA0700013 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (67138CA0700013) Health Insurance Plan, Variant (67138CA0700013-04) have Out Of Country Coverage?
Does (67138CA0700013) Health Insurance Plan, Variant (67138CA0700013-04) have Out of Service Area Coverage?
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