Blue Community Gold HMO℠ 601 - 75605NM0390143 Health Insurance Plan
Blue Cross Blue Shield of New Mexico health insurance plan with the Plan ID 75605NM0390143. The plan is called Blue Community Gold HMO℠ 601.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.78% (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 18.22% 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 | 75605NM0390143 | ||||||||||||||||||
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| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | New Mexico | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross Blue Shield of New Mexico | ||||||||||||||||||
| Health Insurance Plan Variant | 75605NM0390143-01 | ||||||||||||||||||
| Provider Network(s) | ['NMN002'] | ||||||||||||||||||
| 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 - 75605NM0390143-01 |
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| Last Plan Update Date | Tue, 09 May 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan Variant 75605NM0390143-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.817764918 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| 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 | 0.00% |
| 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 | 0.00% |
| 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 | per person not applicable | per group not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol |
| EHB Percent of Total Premium | 100% |
| First Tier Utilization | 85% |
| Formulary ID | NMF013 |
| HIOS Product ID | 75605NM039 |
| Import Date | 5/9/2023 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 75605 |
| 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 | 30.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $2500 per person | $7500 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $2,500 |
| Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 30.00% |
| Medical EHB Deductible, In Network (Tier 2), Family | $2500 per person | $7500 per group |
| Medical EHB Deductible, In Network (Tier 2), Individual | $2,500 |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | NMN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Coverage outside the country is available for Emergency and Urgent Care services only. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Coverage outside our service area is available for Emergency and Urgent Care services only. |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 75605NM0390143-01 |
| Plan Marketing Name | Blue Community Gold HMO℠ 601 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Blue Community Gold HMO℠ 601 HDHP |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,000 |
| SBC Scenario, Having a Baby, Copayment | $30 |
| 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 | $700 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $700 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,700 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 15% |
| Service Area ID | NMS022 |
| Source Name | SERFF |
| Plan ID | 75605NM0390143 |
| State Code | NM |
| 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 | $4500 per person | $13500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $4,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family | $4500 per person | $13500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $4,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Blue Community Gold HMO℠ 601 Health Insurance Plan, 75605NM0390143
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Blue Community Gold HMO℠ 601, 75605NM0390143 Health Insurance Plan, 75605NM0390143
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Does Blue Community Gold HMO℠ 601 Health Insurance Plan, 75605NM0390143 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (75605NM0390143) Health Insurance Plan, Variant (75605NM0390143-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol
Does (75605NM0390143) Health Insurance Plan, Variant (75605NM0390143-01) have Out Of Country Coverage?
Yes. Details: Coverage outside the country is available for Emergency and Urgent Care services only.
Does (75605NM0390143) Health Insurance Plan, Variant (75605NM0390143-01) have Out of Service Area Coverage?
Yes. Details: Coverage outside our service area is available for Emergency and Urgent Care services only.
Does (75605NM0390143) Health Insurance Plan, Variant (75605NM0390143-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol
Does Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan, Variant (75605NM0390143-01) offer Disease Management Programs for Asthma?
Yes, the Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan Variant
75605NM0390143-01 offers Disease
Management Program for Asthma.
Does Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan, Variant (75605NM0390143-01) offer Disease Management Programs for Heart disease?
Yes, the Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan Variant
75605NM0390143-01 offers Disease
Management Program for Heart disease.
Does Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan, Variant (75605NM0390143-01) offer Disease Management Programs for Depression?
Yes, the Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan Variant
75605NM0390143-01 offers Disease
Management Program for Depression.
Does Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan, Variant (75605NM0390143-01) offer Disease Management Programs for Diabetes?
Yes, the Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan Variant
75605NM0390143-01 offers Disease
Management Program for Diabetes.
Does Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan, Variant (75605NM0390143-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan Variant
75605NM0390143-01 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan, Variant (75605NM0390143-01) offer Disease Management Programs for Low back pain?
Yes, the Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan Variant
75605NM0390143-01 offers Disease
Management Program for Low back pain.
Does Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan, Variant (75605NM0390143-01) offer Disease Management Programs for Pregnancy?
Yes, the Blue Community Gold HMO℠ 601 HDHP Health Insurance Plan Variant
75605NM0390143-01 offers Disease
Management Program for Pregnancy.
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