SimplyBlue Plus Gold 21, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, FP, Preventive Rx, Acupuncture - 78124NY1000313 Health Insurance Plan
Excellus Health Plan, Inc health insurance plan with the Plan ID 78124NY1000313. The plan is called SimplyBlue Plus Gold 21, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, FP, Preventive Rx, Acupuncture.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 79.38% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 20.62% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 78124NY1000313 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | Excellus Health Plan, Inc | ||||||||||||||||||
| Health Insurance Plan Variant | 78124NY1000313-01 | ||||||||||||||||||
| 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 21, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, FP, Preventive Rx, Acupuncture Health Insurance Plan Variant 78124NY1000313-01 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 |
| Dental Only Plan | No |
| First Tier Utilization | 100% |
| Formulary ID | NYF036 |
| HIOS Product ID | 78124NY100 |
| HSA/HRA Employer Contribution | Yes |
| HSA/HRA Employer Contribution Amount | $0.00 |
| Import Date | 2/12/2024 |
| HSA Eligible | Yes |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 79.38% |
| Issuer ID | 78124 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| 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) | 78124NY1000313-01 |
| Plan Marketing Name | SimplyBlue Plus Gold 21, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, FP, Preventive Rx, Acupuncture |
| Plan Type | PPO |
| Plan Variant Marketing Name | SimplyBlue Plus Gold 21, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, FP, Preventive Rx, Acupuncture |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $690 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $800 |
| SBC Scenario, Having Diabetes, Deductible | $2,000 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $220 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NYS006 |
| Source Name | SERFF |
| Plan ID | 78124NY1000313 |
| 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 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $4000 per person | $4000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| TEHBDedOutofNetFamily | $10000 per person | $10000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $5,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $8050 per person | $11000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $20000 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 21, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, FP, Preventive Rx, Acupuncture Health Insurance Plan, 78124NY1000313
| 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 21, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, FP, Preventive Rx, Acupuncture, 78124NY1000313 Health Insurance Plan, 78124NY1000313
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Does SimplyBlue Plus Gold 21, NS, OON, Excellus BCBS PPO, Dep25, Pediatric Dental, Adult Vision, DP, FP, Preventive Rx, Acupuncture Health Insurance Plan, 78124NY1000313 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (78124NY1000313) Health Insurance Plan, Variant (78124NY1000313-01) have Out Of Country Coverage?
Does (78124NY1000313) Health Insurance Plan, Variant (78124NY1000313-01) 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