Bronze Standard HSA, Expanded Bronze, ST, INN, Univera EPO Local, Pediatric Dental, Dep25 - 78124NY0950003 Health Insurance Plan
Excellus Health Plan, Inc health insurance plan with the Plan ID 78124NY0950003. The plan is called Bronze Standard HSA, Expanded Bronze, ST, INN, Univera EPO Local, Pediatric Dental, Dep25.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.54% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.46% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 78124NY0950003 | ||||||||||||||||||
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| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | Excellus Health Plan, Inc | ||||||||||||||||||
| Health Insurance Plan Variant | 78124NY0950003-01 | ||||||||||||||||||
| Provider Network(s) | ['NYN011'] | ||||||||||||||||||
| 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 - 78124NY0950003-01 |
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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 |
Bronze Standard HSA, Expanded Bronze, ST, INN, Univera EPO Local, Pediatric Dental, Dep25 Health Insurance Plan Variant 78124NY0950003-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2023 |
| Child-Only Offering | Allows Adult-Only |
| Child Only Plan ID | 78124NY0950005 |
| Composite Rating Offered | No |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 99.83% |
| First Tier Utilization | 100% |
| Formulary ID | NYF011 |
| HIOS Product ID | 78124NY095 |
| Import Date | 1/23/2023 |
| HSA Eligible | Yes |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 64.54% |
| Issuer ID | 78124 |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | NYN011 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services Only |
| Out of Service Area Coverage | No |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 78124NY0950003-01 |
| Plan Marketing Name | Bronze Standard HSA, Expanded Bronze, ST, INN, Univera EPO Local, Pediatric Dental, Dep25 |
| Plan Type | EPO |
| Plan Variant Marketing Name | Bronze Standard HSA, Expanded Bronze, ST, INN, Univera EPO Local, Pediatric Dental, Dep25 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $800 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $6,100 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,420 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| 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 | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NYS003 |
| Source Name | SERFF |
| Plan ID | 78124NY0950003 |
| 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 |
| 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% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $6100 per person | $12200 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,100 |
| TEHBDedOutofNetFamily | $0 per person | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $6900 per person | $13800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,900 |
| 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 Bronze Standard HSA, Expanded Bronze, ST, INN, Univera EPO Local, Pediatric Dental, Dep25 Health Insurance Plan, 78124NY0950003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Bronze Standard HSA, Expanded Bronze, ST, INN, Univera EPO Local, Pediatric Dental, Dep25, 78124NY0950003 Health Insurance Plan, 78124NY0950003
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Does Bronze Standard HSA, Expanded Bronze, ST, INN, Univera EPO Local, Pediatric Dental, Dep25 Health Insurance Plan, 78124NY0950003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (78124NY0950003) Health Insurance Plan, Variant (78124NY0950003-01) have Out Of Country Coverage?
Yes. Details: Emergency Services Only
Does (78124NY0950003) Health Insurance Plan, Variant (78124NY0950003-01) have Out of Service Area Coverage?
No, unfortunately there
is no Out of Service Area Coverage for this Health Insurance
Plan (variant of plan).
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