Blue Connect Copay 80/60 $1000 (N) - 19636LA0240002 Health Insurance Plan
HMO Louisiana, Inc. health insurance plan with the Plan ID 19636LA0240002. The plan is called Blue Connect Copay 80/60 $1000 (N).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.19% (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 20.81% 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 | 19636LA0240002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Louisiana | ||||||||||||||||||
| Health Insurance Issuer | HMO Louisiana, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 19636LA0240002-00 | ||||||||||||||||||
| Provider Network(s) | ['LAN006'] | ||||||||||||||||||
| 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 - 19636LA0240002-00 Standard On Exchange Plan - 19636LA0240002-01 |
||||||||||||||||||
| Last Plan Update Date | Thu, 19 Aug 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Blue Connect Copay 80/60 $1000 (N) Health Insurance Plan Variant 19636LA0240002-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.791861256 |
| 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 Gold Off Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $500 per person |
| Drug EHB Deductible, Combined In/Out of Network, Individual | $500 |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | per group not applicable |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $500 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $500 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | $500 per person |
| Drug EHB Deductible, Out of Network, Individual | $500 |
| 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 | LAF009 |
| Formulary URL | URL |
| HIOS Product ID | 19636LA024 |
| Import Date | 8/19/2021 15:35 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 19636 |
| Issuer Marketplace Marketing Name | HMO Louisiana |
| 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 Group | $18000 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $6000 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $6,000 |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $1000 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,000 |
| Medical EHB Deductible, Out of Network, Family Per Group | $15000 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $5000 per person |
| Medical EHB Deductible, Out of Network, Individual | $5,000 |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | LAN006 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency and non-emergency coverage subject to Blue Card Worldwide rules. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Coverage available for covered benefits |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 19636LA0240002-00 |
| Plan Marketing Name | Blue Connect Copay 80/60 $1000 (N) |
| Plan Type | POS |
| Plan Variant Marketing Name | Blue Connect Copay 80/60 $1000 (N) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,210 |
| SBC Scenario, Having a Baby, Copayment | $60 |
| SBC Scenario, Having a Baby, Deductible | $1,010 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $720 |
| SBC Scenario, Having Diabetes, Copayment | $430 |
| SBC Scenario, Having Diabetes, Deductible | $510 |
| SBC Scenario, Having Diabetes, Limit | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $650 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $250 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | LAS005 |
| Source Name | HIOS |
| Specialty Drug Maximum Coinsurance | $250 |
| Plan ID | 19636LA0240002 |
| State Code | LA |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $69600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $34800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $34,800 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $52200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $26100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $26,100 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Blue Connect Copay 80/60 $1000 (N) Health Insurance Plan, 19636LA0240002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Connect Copay 80/60 $1000 (N), 19636LA0240002 Health Insurance Plan, 19636LA0240002
-
Does Blue Connect Copay 80/60 $1000 (N) Health Insurance Plan, 19636LA0240002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (19636LA0240002) Health Insurance Plan, Variant (19636LA0240002-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Does (19636LA0240002) Health Insurance Plan, Variant (19636LA0240002-00) have Out Of Country Coverage?
Yes. Details: Emergency and non-emergency coverage subject to Blue Card Worldwide rules.
Does (19636LA0240002) Health Insurance Plan, Variant (19636LA0240002-00) have Out of Service Area Coverage?
Yes. Details: Coverage available for covered benefits
Does (19636LA0240002) Health Insurance Plan, Variant (19636LA0240002-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Does Blue Connect Copay 80/60 $1000 (N) Health Insurance Plan, Variant (19636LA0240002-00) offer Disease Management Programs for Asthma?
Yes, the Blue Connect Copay 80/60 $1000 (N) Health Insurance Plan Variant
19636LA0240002-00 offers Disease
Management Program for Asthma.
Does Blue Connect Copay 80/60 $1000 (N) Health Insurance Plan, Variant (19636LA0240002-00) offer Disease Management Programs for Heart disease?
Yes, the Blue Connect Copay 80/60 $1000 (N) Health Insurance Plan Variant
19636LA0240002-00 offers Disease
Management Program for Heart disease.
Does Blue Connect Copay 80/60 $1000 (N) Health Insurance Plan, Variant (19636LA0240002-00) offer Disease Management Programs for Diabetes?
Yes, the Blue Connect Copay 80/60 $1000 (N) Health Insurance Plan Variant
19636LA0240002-00 offers Disease
Management Program for Diabetes.
Does Blue Connect Copay 80/60 $1000 (N) Health Insurance Plan, Variant (19636LA0240002-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Blue Connect Copay 80/60 $1000 (N) Health Insurance Plan Variant
19636LA0240002-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Blue Connect Copay 80/60 $1000 (N) Health Insurance Plan, Variant (19636LA0240002-00) offer Disease Management Programs for Pregnancy?
Yes, the Blue Connect Copay 80/60 $1000 (N) Health Insurance Plan Variant
19636LA0240002-00 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