BlueChoice HMO Referral Silver 5350 Virtual Connect - 86052DC0480014 Health Insurance Plan
CareFirst BlueChoice, Inc. health insurance plan with the Plan ID 86052DC0480014. The plan is called BlueChoice HMO Referral Silver 5350 Virtual Connect.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.41% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.59% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 74.11% (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 25.89% 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 | 86052DC0480014 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | District of Columbia | ||||||||||||||||||
| Health Insurance Issuer | CareFirst BlueChoice, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 86052DC0480014-01 | ||||||||||||||||||
| Provider Network(s) | ['DCN003'] | ||||||||||||||||||
| 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 | |||||||||||||||||||
| Last Plan Update Date | Mon, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan Variant 86052DC0480014-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.741088858 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver 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 | $450 per person | per group not applicable |
| Drug EHB Deductible, In Network (Tier 1), Individual | $450 |
| 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 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol |
| First Tier Utilization | 100% |
| Formulary ID | DCF014 |
| HIOS Product ID | 86052DC048 |
| HSA/HRA Employer Contribution | No |
| Import Date | 1/23/2023 |
| Inpatient Copayment Maximum Days | 5 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 71.41% |
| Issuer ID | 86052 |
| Market Coverage | SHOP (Small Group) |
| 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 | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $5350 per person | $10700 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $5,350 |
| 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 | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | DCN003 |
| 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 | Emergency Services Only |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 86052DC0480014-01 |
| Plan Marketing Name | BlueChoice HMO Referral Silver 5350 Virtual Connect |
| Plan Type | HMO |
| Plan Variant Marketing Name | BlueChoice HMO Referral Silver 5350 Virtual Connect |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,140 |
| SBC Scenario, Having a Baby, Deductible | $5,350 |
| SBC Scenario, Having a Baby, Limit | $10 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $865 |
| SBC Scenario, Having Diabetes, Deductible | $3,090 |
| 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 | $1,900 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | DCS004 |
| Source Name | SERFF |
| Specialty Drug Maximum Coinsurance | $150 |
| Plan ID | 86052DC0480014 |
| State Code | DC |
| 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 | $8800 per person | $17600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,800 |
| 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 | Yes |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan, 86052DC0480014
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about BlueChoice HMO Referral Silver 5350 Virtual Connect, 86052DC0480014 Health Insurance Plan, 86052DC0480014
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Does BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan, 86052DC0480014 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (86052DC0480014) Health Insurance Plan, Variant (86052DC0480014-01) 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 (86052DC0480014) Health Insurance Plan, Variant (86052DC0480014-01) have Out Of Country Coverage?
Yes. Details: Emergency Services Only
Does (86052DC0480014) Health Insurance Plan, Variant (86052DC0480014-01) have Out of Service Area Coverage?
Yes. Details: Emergency Services Only
Does (86052DC0480014) Health Insurance Plan, Variant (86052DC0480014-01) 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 BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan, Variant (86052DC0480014-01) offer Disease Management Programs for Asthma?
Yes, the BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan Variant
86052DC0480014-01 offers Disease
Management Program for Asthma.
Does BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan, Variant (86052DC0480014-01) offer Disease Management Programs for Heart disease?
Yes, the BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan Variant
86052DC0480014-01 offers Disease
Management Program for Heart disease.
Does BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan, Variant (86052DC0480014-01) offer Disease Management Programs for Depression?
Yes, the BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan Variant
86052DC0480014-01 offers Disease
Management Program for Depression.
Does BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan, Variant (86052DC0480014-01) offer Disease Management Programs for Diabetes?
Yes, the BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan Variant
86052DC0480014-01 offers Disease
Management Program for Diabetes.
Does BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan, Variant (86052DC0480014-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan Variant
86052DC0480014-01 offers Disease
Management Program for High blood pressure & high cholesterol.
Does BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan, Variant (86052DC0480014-01) offer Disease Management Programs for Low back pain?
Yes, the BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan Variant
86052DC0480014-01 offers Disease
Management Program for Low back pain.
Does BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan, Variant (86052DC0480014-01) offer Disease Management Programs for Pregnancy?
Yes, the BlueChoice HMO Referral Silver 5350 Virtual Connect Health Insurance Plan Variant
86052DC0480014-01 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