*BlueSolutions for HSA Direct 1700/3400 - 15287RI1150002 Health Insurance Plan
Blue Cross & Blue Shield of Rhode Island health insurance plan with the Plan ID 15287RI1150002. The plan is called *BlueSolutions for HSA Direct 1700/3400.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.75% (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 20.25% 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 | 15287RI1150002 | ||||||||||||||||||
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| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Rhode Island | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross & Blue Shield of Rhode Island | ||||||||||||||||||
| Health Insurance Plan Variant | 15287RI1150002-01 | ||||||||||||||||||
| Provider Network(s) | ['RIN001'] | ||||||||||||||||||
| 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 - 15287RI1150002-01 |
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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 |
*BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan Variant 15287RI1150002-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.797505778 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy, Weight Loss Programs, Low Back Pain, High Blood Pressure & High Cholesterol |
| EHB Percent of Total Premium | 99.93% |
| First Tier Utilization | 100% |
| Formulary ID | RIF004 |
| HIOS Product ID | 15287RI115 |
| Import Date | 1/23/2023 |
| HSA Eligible | Yes |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 15287 |
| 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 | Yes |
| Network ID | RIN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Coverage for urgent or emergent care only as well as medically necessary services. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Coverage for urgent or emergent care only as well as medically necessary services. |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 15287RI1150002-01 |
| Plan Level Exclusions | This plan does not include coverage that is not medically necessary. Abortions for which federal funding is not allowed in accordance with the Affordable Care Act section 130(b)(1)(B)(i) are not covered, namely all abortions except in the case of rape or incest, or for a pregnancy which places the woman in danger of death unless the abortion is performed. This plan does not cover services rendered by excluded providers, naturopaths, homeopaths, providers or facilities who are not legally qualified or licensed, Christian Scientist Practitioners, Acupuncturists, or Massage Therapists. |
| Plan Marketing Name | *BlueSolutions for HSA Direct 1700/3400 |
| Plan Type | PPO |
| Plan Variant Marketing Name | *BlueSolutions for HSA Direct 1700/3400 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $50 |
| SBC Scenario, Having a Baby, Deductible | $1,700 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $400 |
| SBC Scenario, Having Diabetes, Deductible | $1,700 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,700 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | RIS001 |
| Source Name | SERFF |
| Plan ID | 15287RI1150002 |
| State Code | RI |
| 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 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| 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 person not applicable | $3400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,700 |
| TEHBDedOutofNetFamily | per person not applicable | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $5200 per person | $10400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,200 |
| 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 *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan, 15287RI1150002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about *BlueSolutions for HSA Direct 1700/3400, 15287RI1150002 Health Insurance Plan, 15287RI1150002
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Does *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan, 15287RI1150002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (15287RI1150002) Health Insurance Plan, Variant (15287RI1150002-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy, Weight Loss Programs, Low Back Pain, High Blood Pressure & High Cholesterol
Does (15287RI1150002) Health Insurance Plan, Variant (15287RI1150002-01) have Out Of Country Coverage?
Yes. Details: Coverage for urgent or emergent care only as well as medically necessary services.
Does (15287RI1150002) Health Insurance Plan, Variant (15287RI1150002-01) have Out of Service Area Coverage?
Yes. Details: Coverage for urgent or emergent care only as well as medically necessary services.
Does (15287RI1150002) Health Insurance Plan, Variant (15287RI1150002-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy, Weight Loss Programs, Low Back Pain, High Blood Pressure & High Cholesterol
Does *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan, Variant (15287RI1150002-01) offer Disease Management Programs for Asthma?
Yes, the *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan Variant
15287RI1150002-01 offers Disease
Management Program for Asthma.
Does *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan, Variant (15287RI1150002-01) offer Disease Management Programs for Heart disease?
Yes, the *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan Variant
15287RI1150002-01 offers Disease
Management Program for Heart disease.
Does *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan, Variant (15287RI1150002-01) offer Disease Management Programs for Diabetes?
Yes, the *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan Variant
15287RI1150002-01 offers Disease
Management Program for Diabetes.
Does *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan, Variant (15287RI1150002-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan Variant
15287RI1150002-01 offers Disease
Management Program for High blood pressure & high cholesterol.
Does *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan, Variant (15287RI1150002-01) offer Disease Management Programs for Low back pain?
Yes, the *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan Variant
15287RI1150002-01 offers Disease
Management Program for Low back pain.
Does *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan, Variant (15287RI1150002-01) offer Disease Management Programs for Pregnancy?
Yes, the *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan Variant
15287RI1150002-01 offers Disease
Management Program for Pregnancy.
Does *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan, Variant (15287RI1150002-01) offer Disease Management Programs for Weight loss programs?
Yes, the *BlueSolutions for HSA Direct 1700/3400 Health Insurance Plan Variant
15287RI1150002-01 offers Disease
Management Program for Weight loss programs.
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