St Luke's Health Plan Gold - 92170ID0180003 Health Insurance Plan
St. Luke's Health Plan health insurance plan with the Plan ID 92170ID0180003. The plan is called St Luke's Health Plan Gold.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.97% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.03% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 92170ID0180003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Idaho | ||||||||||||||||||
| Health Insurance Issuer | St. Luke's Health Plan | ||||||||||||||||||
| Health Insurance Plan Variant | 92170ID0180003-01 | ||||||||||||||||||
| Provider Network(s) | ['IDN001'] | ||||||||||||||||||
| 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 |
St Luke's Health Plan Gold Health Insurance Plan Variant 92170ID0180003-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.809675058 |
| 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 | IDF004 |
| HIOS Product ID | 92170ID018 |
| 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 ID | 92170 |
| 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 | IDN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Medical and Pharmacy |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 92170ID0180003-01 |
| Plan Level Exclusions | No |
| Plan Marketing Name | St Luke's Health Plan Gold |
| Plan Type | POS |
| Plan Variant Marketing Name | St Luke's Health Plan Gold |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $700 |
| SBC Scenario, Having a Baby, Copayment | $600 |
| SBC Scenario, Having a Baby, Deductible | $1,800 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $600 |
| SBC Scenario, Having Diabetes, Copayment | $200 |
| SBC Scenario, Having Diabetes, Deductible | $1,800 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | IDS002 |
| Source Name | SERFF |
| Plan ID | 92170ID0180003 |
| State Code | ID |
| 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 | 10.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $1800 per person | $3600 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,800 |
| TEHBDedOutofNetFamily | $3600 per person | $7200 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $3,600 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $7750 per person | $15500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,750 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $15500 per person | $31000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $15,500 |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of St Luke's Health Plan Gold Health Insurance Plan, 92170ID0180003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about St Luke's Health Plan Gold, 92170ID0180003 Health Insurance Plan, 92170ID0180003
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Does St Luke's Health Plan Gold Health Insurance Plan, 92170ID0180003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (92170ID0180003) Health Insurance Plan, Variant (92170ID0180003-01) have Out Of Country Coverage?
Does (92170ID0180003) Health Insurance Plan, Variant (92170ID0180003-01) 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