Avera Standard 2000 - 60536SD0020051 Health Insurance Plan
Avera Health Plans, Inc. health insurance plan with the Plan ID 60536SD0020051. The plan is called Avera Standard 2000.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 60536SD0020051 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| 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 | 60536SD0020051-02 | ||||||||||||||||||
| Provider Network(s) | ['SDN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 60536SD0020051-00 Standard On Exchange Plan - 60536SD0020051-01 |
||||||||||||||||||
| Last Plan Update Date | Wed, 17 Aug 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Avera Standard 2000 Health Insurance Plan, 60536SD0020051-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime |
YES | 0.00% |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Limit: 1.0 Visit(s) per 6 Months |
YES | $0.00, 0.00% |
100.00% |
| Chemotherapy
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Chiropractic Care
Preauthorization required after 20 visits per plan year. No coverage for services without preauthorization. |
YES | $0.00, 0.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | $0.00, 0.00% |
100.00% |
| Diabetes Education
Limit: 8.0 Visit(s) per Year State law allows two education programs per lifetime and up to 8 follow-up visits per year |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Dialysis
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Durable Medical Equipment
Exclusions: Certain durable medical equipment require preauthorization. No coverage for services without preauthorization. |
YES | $0.00, 0.00% |
100.00% |
| Emergency Room Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
Exclusions: Preauthorization for non-emergency transportation. No coverage for services without preauthorization. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Habilitation Services
Treatment for Autism Spectrum Disorder (ASD) with speech therapy, occupational therapy, or physical therapy is covered. Use of Applied Behavioral Analysis (ABA) for the treatment of ASD is covered with the following minimum coverage limits: 1) through age 6: 1300 hours per benefit period; 2) ages 7-13: 900 hours per benefit period; 3) ages 14-18: 450 hours per benefit period. Preauthorization required after 30 visits per plan year for each therapy: physical, occupational and speech. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Exclusions: 60-visit limit per plan year for services from non-participating providers. One visit equals a maximum of 4 hours, including private duty nursing. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Hospice Services
Limit: 185.0 Days per Year |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: Some imaging requires preauthorization. Major lab and X-ray services may include PET scan, MRI, CT scan, SPECT scan, cardiovascular, nuclear medicine and MRA. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: Preauthorization required. No coverage for services without preauthorization |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Inpatient Physician and Surgical Services
Exclusions: Preauthorization required. No coverage for services without preauthorization |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Laboratory Outpatient and Professional Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Frequency limitations may apply |
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
Exclusions: Preauthorization for non-emergency transportation. No coverage for services without preauthorization. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Mental/Behavioral Health Outpatient Services
Coinsurance will apply for services other than therapy performed in the office or any service at a facility. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Non-Preferred Brand Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Frequency limitations may apply |
YES | $0.00, 0.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Rehabilitation Services
Preauthorization required after 30 visits per plan year for each therapy: physical, occupational and speech. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Preferred Brand Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Prenatal and Postnatal Care
Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Preventive Care/Screening/Immunization
Age and frequency limitations may apply |
YES | $0.00, 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Private-Duty Nursing
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Prosthetic Devices
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Radiation
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Reconstructive Surgery
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Preauthorization required after 30 visits per plan year. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Rehabilitative Speech Therapy
Preauthorization required after 30 visits per plan year. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 100.0 Days per Admission 100-day confinement limit is for services from participating providers. 60-day confinement limit for services from non-participating providers. Same confinement limit if readmitted with same diagnosis within 60 days. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Specialist Visit
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Specialty Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Substance Abuse Disorder Outpatient Services
Coinsurance will apply for services other than therapy performed in the office or any service at a facility. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Transplant
|
YES | $0.00, 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Urgent Care Centers or Facilities
In-network benefit for services outside of service area. When using Out-of-Network Provider inside service area you may contact the plan to determine if your visit qualifies for in-network benefits. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Age and frequency limitations may apply |
YES | $0.00, 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Avera Standard 2000 AI/AN Zero Cost Plan Health Insurance Plan Variant 60536SD0020051-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Design 1 |
| 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 | SDF005 |
| Formulary URL | URL |
| HIOS Product ID | 60536SD002 |
| Import Date | 8/17/2022 20:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| 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 | Gold |
| 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 | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 60536SD0020051-02 |
| 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 Standard 2000 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Avera Standard 2000 AI/AN Zero Cost Plan |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | SDS001 |
| Source Name | SERFF |
| Plan ID | 60536SD0020051 |
| State Code | SD |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| 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 | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Avera Standard 2000 Health Insurance Plan, 60536SD0020051
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Avera Standard 2000, 60536SD0020051 Health Insurance Plan, 60536SD0020051
-
Does Avera Standard 2000 Health Insurance Plan, 60536SD0020051 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (60536SD0020051) Health Insurance Plan, Variant (60536SD0020051-02) offer Disease Management Programs?
Does (60536SD0020051) Health Insurance Plan, Variant (60536SD0020051-02) have Out Of Country Coverage?
Does (60536SD0020051) Health Insurance Plan, Variant (60536SD0020051-02) have Out of Service Area Coverage?
Does (60536SD0020051) Health Insurance Plan, Variant (60536SD0020051-02) offer Disease Management Programs?
Does Avera Standard 2000 AI/AN Zero Cost Plan Health Insurance Plan, Variant (60536SD0020051-02) offer Disease Management Programs for Asthma?
Does Avera Standard 2000 AI/AN Zero Cost Plan Health Insurance Plan, Variant (60536SD0020051-02) offer Disease Management Programs for Heart disease?
Does Avera Standard 2000 AI/AN Zero Cost Plan Health Insurance Plan, Variant (60536SD0020051-02) offer Disease Management Programs for Diabetes?
Does Avera Standard 2000 AI/AN Zero Cost Plan Health Insurance Plan, Variant (60536SD0020051-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Avera Standard 2000 AI/AN Zero Cost Plan Health Insurance Plan, Variant (60536SD0020051-02) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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