Silver Standard, Silver, Child Only, ST, INN, Excellus BCBS EPO, Pediatric Dental - 78124NY0890011 Health Insurance Plan

Excellus Health Plan, Inc health insurance plan with the Plan ID 78124NY0890011. The plan is called Silver Standard, Silver, Child Only, ST, INN, Excellus BCBS EPO, Pediatric Dental.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.99% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.01% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 78124NY0890011
Health Insurance Plan Year 2024
State New York
Health Insurance Issuer Excellus Health Plan, Inc
Health Insurance Plan Variant 78124NY0890011-01
Provider Network(s) ['NYN005']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT).

Providers New York All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard On Exchange Plan - 78124NY0890011-01

Open to Indians below 300% FPL - 78124NY0890011-02

Open to Indians above 300% FPL - 78124NY0890011-03

73% AV Silver Plan - 78124NY0890011-04

87% AV Silver Plan - 78124NY0890011-05

94% AV Silver Plan - 78124NY0890011-06

Last Plan Update Date Mon, 12 Feb 2024 00:00 GMT
Last Import Date Thu, 21 Nov 2024 00:44 GMT

Silver Standard, Silver, Child Only, ST, INN, Excellus BCBS EPO, Pediatric Dental Health Insurance Plan Variant 78124NY0890011-01 Attributes

Plan Attribute Value
Business Year 2024
Child-Only Offering Allows Child-Only
Composite Rating Offered No
CSR Variation Type Standard Silver On Exchange 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 0.00%
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 $0 per person | $0 per group
Drug EHB Deductible, Out of Network, Individual $0
Dental Only Plan No
Design Type Not Applicable
EHB Percent of Total Premium 99%
First Tier Utilization 100%
Formulary ID NYF016
HIOS Product ID 78124NY089
Import Date 2/12/2024
HSA Eligible No
IsItANewPlan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 71.99%
Issuer ID 78124
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 0.00%
Medical EHB Deductible, In Network (Tier 1), Family $2100 per person | $4200 per group
Medical EHB Deductible, In Network (Tier 1), Individual $2,100
Medical EHB Deductible, Out of Network, Family $0 per person | $0 per group
Medical EHB Deductible, Out of Network, Individual $0
Metal Level Silver
Multiple In Network Tiers No
National Network Yes
Network ID NYN005
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Services Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description BlueCard Worldwide
Plan Effective Date 1/1/2024
Plan Expiration Date 12/31/2024
Plan ID (Standard Component ID with Variant) 78124NY0890011-01
Plan Marketing Name Silver Standard, Silver, Child Only, ST, INN, Excellus BCBS EPO, Pediatric Dental
Plan Type EPO
Plan Variant Marketing Name Silver Standard, Silver, Child Only, ST, INN, Excellus BCBS EPO, Pediatric Dental
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $2,000
SBC Scenario, Having a Baby, Deductible $2,100
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $940
SBC Scenario, Having Diabetes, Deductible $2,100
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $270
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,100
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID NYS001
Source Name SERFF
Plan ID 78124NY0890011
State Code NY
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 $9450 per person | $18900 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,450
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family $0 per person | $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $0
Unique Plan Design Yes
Version Number 1
Wellness Program Offered No

Copay & Coinsurance of Silver Standard, Silver, Child Only, ST, INN, Excellus BCBS EPO, Pediatric Dental Health Insurance Plan, 78124NY0890011

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Silver Standard, Silver, Child Only, ST, INN, Excellus BCBS EPO, Pediatric Dental, 78124NY0890011 Health Insurance Plan, 78124NY0890011

  • Does Silver Standard, Silver, Child Only, ST, INN, Excellus BCBS EPO, Pediatric Dental Health Insurance Plan, 78124NY0890011 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (78124NY0890011) Health Insurance Plan, Variant (78124NY0890011-01) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (78124NY0890011) Health Insurance Plan, Variant (78124NY0890011-01) have Out of Service Area Coverage?

    Yes. Details: BlueCard Worldwide

 

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