Bassett Preferred Gold, NS, INN, Adult/Family Dental, Dep29, Tiered Network, Acupuncture - 78124NY0920001 Health Insurance Plan
Excellus Health Plan, Inc health insurance plan with the Plan ID 78124NY0920001. The plan is called Bassett Preferred Gold, NS, INN, Adult/Family Dental, Dep29, Tiered Network, Acupuncture.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.90% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.10% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 78124NY0920001 | ||||||||||||||||||
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| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | Excellus Health Plan, Inc | ||||||||||||||||||
| Health Insurance Plan Variant | 78124NY0920001-01 | ||||||||||||||||||
| Provider Network(s) | ['NYN006'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 May 2024 06:08 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 78124NY0920001-01 |
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| Last Plan Update Date | Mon, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Bassett Preferred Gold, NS, INN, Adult/Family Dental, Dep29, Tiered Network, Acupuncture Health Insurance Plan Variant 78124NY0920001-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0% |
| Drug EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 0% |
| Drug EHB Deductible, In Network (Tier 2), Family | $0 per person | $0 per group |
| Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family | $0 per person | $0 per group |
| Drug EHB Deductible, Out of Network, Individual | $0 |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 99.91% |
| First Tier Utilization | 66% |
| Formulary ID | NYF003 |
| HIOS Product ID | 78124NY092 |
| Import Date | 1/23/2023 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 81.90% |
| Issuer ID | 78124 |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 0% |
| Medical EHB Deductible, In Network (Tier 1), Family | $850 per person | $1700 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $850 |
| Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 0% |
| Medical EHB Deductible, In Network (Tier 2), Family | $2500 per person | $5000 per group |
| Medical EHB Deductible, In Network (Tier 2), Individual | $2,500 |
| Medical EHB Deductible, Out of Network, Family | $0 per person | $0 per group |
| Medical EHB Deductible, Out of Network, Individual | $0 |
| Metal Level | Gold |
| Multiple In Network Tiers | Yes |
| National Network | Yes |
| Network ID | NYN006 |
| 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 | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 78124NY0920001-01 |
| Plan Marketing Name | Bassett Preferred Gold, NS, INN, Adult/Family Dental, Dep29, Tiered Network, Acupuncture |
| Plan Type | EPO |
| Plan Variant Marketing Name | Bassett Preferred Gold, NS, INN, Adult/Family Dental, Dep29, Tiered Network, Acupuncture |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,000 |
| SBC Scenario, Having a Baby, Deductible | $2,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $710 |
| SBC Scenario, Having Diabetes, Deductible | $2,500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $80 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 34% |
| Service Area ID | NYS005 |
| Source Name | SERFF |
| Plan ID | 78124NY0920001 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $8500 per person | $17000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family | $8500 per person | $17000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $8,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $0 per person | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Bassett Preferred Gold, NS, INN, Adult/Family Dental, Dep29, Tiered Network, Acupuncture Health Insurance Plan, 78124NY0920001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Bassett Preferred Gold, NS, INN, Adult/Family Dental, Dep29, Tiered Network, Acupuncture, 78124NY0920001 Health Insurance Plan, 78124NY0920001
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Does Bassett Preferred Gold, NS, INN, Adult/Family Dental, Dep29, Tiered Network, Acupuncture Health Insurance Plan, 78124NY0920001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (78124NY0920001) Health Insurance Plan, Variant (78124NY0920001-01) have Out Of Country Coverage?
Yes. Details: Emergency Services Only
Does (78124NY0920001) Health Insurance Plan, Variant (78124NY0920001-01) have Out of Service Area Coverage?
Yes. Details: BlueCard Worldwide
Disclaimer: This is based on the import(Date: Tue, 07 May 2024 06:08 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