SimplyBlue Plus Gold 19, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, Acupuncture - 78124NY0990301 Health Insurance Plan
Excellus Health Plan, Inc health insurance plan with the Plan ID 78124NY0990301. The plan is called SimplyBlue Plus Gold 19, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, Acupuncture.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.34% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.66% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 78124NY0990301 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | Excellus Health Plan, Inc | ||||||||||||||||||
| Health Insurance Plan Variant | 78124NY0990301-01 | ||||||||||||||||||
| Provider Network(s) | ['NYN016'] | ||||||||||||||||||
| 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 | |||||||||||||||||||
| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
SimplyBlue Plus Gold 19, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, Acupuncture Health Insurance Plan Variant 78124NY0990301-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold 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 |
| First Tier Utilization | 100% |
| Formulary ID | NYF019 |
| HIOS Product ID | 78124NY099 |
| HSA/HRA Employer Contribution | No |
| 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 | 81.34% |
| Issuer ID | 78124 |
| Market Coverage | SHOP (Small Group) |
| 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 | $2250 per person | $4500 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $2,250 |
| Medical EHB Deductible, Out of Network, Family | $5000 per person | $10000 per group |
| Medical EHB Deductible, Out of Network, Individual | $5,000 |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | NYN016 |
| 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) | 78124NY0990301-01 |
| Plan Marketing Name | SimplyBlue Plus Gold 19, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, Acupuncture |
| Plan Type | PPO |
| Plan Variant Marketing Name | SimplyBlue Plus Gold 19, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, Acupuncture |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,760 |
| SBC Scenario, Having a Baby, Copayment | $290 |
| SBC Scenario, Having a Baby, Deductible | $2,250 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,670 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,030 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $250 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NYS006 |
| Source Name | SERFF |
| Plan ID | 78124NY0990301 |
| 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 | $6850 per person | $13700 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,850 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $10000 per person | $20000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $10,000 |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of SimplyBlue Plus Gold 19, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, Acupuncture Health Insurance Plan, 78124NY0990301
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about SimplyBlue Plus Gold 19, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, Acupuncture, 78124NY0990301 Health Insurance Plan, 78124NY0990301
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Does SimplyBlue Plus Gold 19, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, Acupuncture Health Insurance Plan, 78124NY0990301 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (78124NY0990301) Health Insurance Plan, Variant (78124NY0990301-01) have Out Of Country Coverage?
Does (78124NY0990301) Health Insurance Plan, Variant (78124NY0990301-01) 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