Voyager Gold HSA 3200 - 10091OR0700016 Health Insurance Plan
PacificSource Health Plans health insurance plan with the Plan ID 10091OR0700016. The plan is called Voyager Gold HSA 3200.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.89% (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 19.11% 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 | 10091OR0700016 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Oregon | ||||||||||||||||||
| Health Insurance Issuer | PacificSource Health Plans | ||||||||||||||||||
| Health Insurance Plan Variant | 10091OR0700016-01 | ||||||||||||||||||
| Provider Network(s) | TIER-ONE | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 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 | Tue, 24 Dec 2024 06:21 GMT |
Voyager Gold HSA 3200 Health Insurance Plan Variant 10091OR0700016-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.80894683 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | Yes |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Pregnancy, Diabetes, Heart Disease, Asthma |
| First Tier Utilization | 100% |
| Formulary ID | ORF014 |
| HIOS Product ID | 10091OR070 |
| HSA/HRA Employer Contribution | No |
| Import Date | 2/12/2024 |
| HSA Eligible | Yes |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 10091 |
| 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 | ORN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Care Services Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | In and out-of-network providers |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 10091OR0700016-01 |
| Plan Marketing Name | Voyager Gold HSA 3200 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Voyager Gold HSA 3200 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $3,200 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $3,200 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ORS001 |
| Source Name | SERFF |
| Plan ID | 10091OR0700016 |
| State Code | OR |
| 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 | $3200 per person | $6400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,200 |
| TEHBDedOutofNetFamily | $5000 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 | $3200 per person | $6400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $7500 per person | $15000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $7,500 |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Voyager Gold HSA 3200 Health Insurance Plan, 10091OR0700016
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Voyager Gold HSA 3200, 10091OR0700016 Health Insurance Plan, 10091OR0700016
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Does Voyager Gold HSA 3200 Health Insurance Plan, 10091OR0700016 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (10091OR0700016) Health Insurance Plan, Variant (10091OR0700016-01) offer Disease Management Programs?
Does (10091OR0700016) Health Insurance Plan, Variant (10091OR0700016-01) have Out Of Country Coverage?
Does (10091OR0700016) Health Insurance Plan, Variant (10091OR0700016-01) have Out of Service Area Coverage?
Does (10091OR0700016) Health Insurance Plan, Variant (10091OR0700016-01) offer Disease Management Programs?
Does Voyager Gold HSA 3200 Health Insurance Plan, Variant (10091OR0700016-01) offer Disease Management Programs for Asthma?
Does Voyager Gold HSA 3200 Health Insurance Plan, Variant (10091OR0700016-01) offer Disease Management Programs for Heart disease?
Does Voyager Gold HSA 3200 Health Insurance Plan, Variant (10091OR0700016-01) offer Disease Management Programs for Diabetes?
Does Voyager Gold HSA 3200 Health Insurance Plan, Variant (10091OR0700016-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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