Silver Standard, Silver, Child Only, ST, INN, Univera EPO Local, Pediatric Dental - 78124NY0940011 Health Insurance Plan
Excellus Health Plan, Inc health insurance plan with the Plan ID 78124NY0940011. The plan is called Silver Standard, Silver, Child Only, ST, INN, Univera EPO Local, 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 | 78124NY0940011 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | Excellus Health Plan, Inc | ||||||||||||||||||
| Health Insurance Plan Variant | 78124NY0940011-01 | ||||||||||||||||||
| Provider Network(s) | ['NYN011'] | ||||||||||||||||||
| 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 - 78124NY0940011-01 Open to Indians below 300% FPL - 78124NY0940011-02 Open to Indians above 300% FPL - 78124NY0940011-03 73% AV Silver Plan - 78124NY0940011-04 |
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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 Standard, Silver, Child Only, ST, INN, Univera EPO Local, Pediatric Dental Health Insurance Plan Variant 78124NY0940011-01 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 | 78124NY094 |
| 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 | No |
| Network ID | NYN011 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services Only |
| Out of Service Area Coverage | No |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 78124NY0940011-01 |
| Plan Marketing Name | Silver Standard, Silver, Child Only, ST, INN, Univera EPO Local, Pediatric Dental |
| Plan Type | EPO |
| Plan Variant Marketing Name | Silver Standard, Silver, Child Only, ST, INN, Univera EPO Local, 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 | NYS003 |
| Source Name | SERFF |
| Plan ID | 78124NY0940011 |
| 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, Univera EPO Local, Pediatric Dental Health Insurance Plan, 78124NY0940011
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Silver Standard, Silver, Child Only, ST, INN, Univera EPO Local, Pediatric Dental, 78124NY0940011 Health Insurance Plan, 78124NY0940011
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Does Silver Standard, Silver, Child Only, ST, INN, Univera EPO Local, Pediatric Dental Health Insurance Plan, 78124NY0940011 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (78124NY0940011) Health Insurance Plan, Variant (78124NY0940011-01) have Out Of Country Coverage?
Does (78124NY0940011) Health Insurance Plan, Variant (78124NY0940011-01) 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