Avera 6850 HSA Eligible HDHP - 60536SD0020024 Health Insurance Plan
Avera Health Plans, Inc. health insurance plan with the Plan ID 60536SD0020024. The plan is called Avera 6850 HSA Eligible HDHP.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.94% (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 35.06% 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 | 60536SD0020024 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | South Dakota | ||||||||||||||||||
| Health Insurance Issuer | Avera Health Plans, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 60536SD0020024-00 | ||||||||||||||||||
| Provider Network(s) | ['SDN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 60536SD0020024-00 Standard On Exchange Plan - 60536SD0020024-01 |
||||||||||||||||||
| Last Plan Update Date | Mon, 06 Dec 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Avera 6850 HSA Eligible HDHP Health Insurance Plan Variant 60536SD0020024-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.649449162 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2022 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze Off Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | SDF002 |
| Formulary URL | URL |
| HIOS Product ID | 60536SD002 |
| Import Date | 12/6/2021 20:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 60536 |
| Issuer Marketplace Marketing Name | Avera Health Plans |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | SDN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency or urgent care services are covered if traveling outside of our service area. No coverage for health services if you travel outside our service area for the purpose of seeking medical treatment. |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 60536SD0020024-00 |
| Plan Level Exclusions | Abortion (except when the life of the mother is endangered), acupuncture, cosmetic surgery, dental care for adults, hearing aids, infertility treatment, long-term care, non-emergency care when traveling outside the United States, routine eye care for adults, and weight loss programs. |
| Plan Marketing Name | Avera 6850 HSA Eligible HDHP |
| Plan Type | PPO |
| Plan Variant Marketing Name | Avera 6850 HSA Eligible HDHP |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $6,850 |
| SBC Scenario, Having a Baby, Limit | $100 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,400 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| 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 | SDS001 |
| Source Name | SERFF |
| Plan ID | 60536SD0020024 |
| State Code | SD |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person 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 Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person 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 Per Group | $13700 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6850 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,850 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $20000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $10000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $10,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $13700 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6850 per person |
| 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 Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Avera 6850 HSA Eligible HDHP Health Insurance Plan, 60536SD0020024
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Avera 6850 HSA Eligible HDHP, 60536SD0020024 Health Insurance Plan, 60536SD0020024
-
Does Avera 6850 HSA Eligible HDHP Health Insurance Plan, 60536SD0020024 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (60536SD0020024) Health Insurance Plan, Variant (60536SD0020024-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Does (60536SD0020024) Health Insurance Plan, Variant (60536SD0020024-00) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (60536SD0020024) Health Insurance Plan, Variant (60536SD0020024-00) have Out of Service Area Coverage?
Yes. Details: Emergency or urgent care services are covered if traveling outside of our service area. No coverage for health services if you travel outside our service area for the purpose of seeking medical treatment.
Does (60536SD0020024) Health Insurance Plan, Variant (60536SD0020024-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Does Avera 6850 HSA Eligible HDHP Health Insurance Plan, Variant (60536SD0020024-00) offer Disease Management Programs for Asthma?
Yes, the Avera 6850 HSA Eligible HDHP Health Insurance Plan Variant
60536SD0020024-00 offers Disease
Management Program for Asthma.
Does Avera 6850 HSA Eligible HDHP Health Insurance Plan, Variant (60536SD0020024-00) offer Disease Management Programs for Heart disease?
Yes, the Avera 6850 HSA Eligible HDHP Health Insurance Plan Variant
60536SD0020024-00 offers Disease
Management Program for Heart disease.
Does Avera 6850 HSA Eligible HDHP Health Insurance Plan, Variant (60536SD0020024-00) offer Disease Management Programs for Diabetes?
Yes, the Avera 6850 HSA Eligible HDHP Health Insurance Plan Variant
60536SD0020024-00 offers Disease
Management Program for Diabetes.
Does Avera 6850 HSA Eligible HDHP Health Insurance Plan, Variant (60536SD0020024-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Avera 6850 HSA Eligible HDHP Health Insurance Plan Variant
60536SD0020024-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Avera 6850 HSA Eligible HDHP Health Insurance Plan, Variant (60536SD0020024-00) offer Disease Management Programs for Pregnancy?
Yes, the Avera 6850 HSA Eligible HDHP Health Insurance Plan Variant
60536SD0020024-00 offers Disease
Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Tue, 30 Apr 2024 06:06 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