EmblemHealth, Gold, ST, INN, Prime Network, Child Only, Pediatric Dental - 88582NY0270001 Health Insurance Plan
Health Insurance Plan of Greater New York health insurance plan with the Plan ID 88582NY0270001. The plan is called EmblemHealth, Gold, ST, INN, Prime Network, Child Only, Pediatric Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.98% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.02% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 88582NY0270001 | ||||||||||||||||||
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| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | Health Insurance Plan of Greater New York | ||||||||||||||||||
| Health Insurance Plan Variant | 88582NY0270001-01 | ||||||||||||||||||
| Provider Network(s) | ['NYN006'] | ||||||||||||||||||
| 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 - 88582NY0270001-01 |
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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 |
EmblemHealth, Gold, ST, INN, Prime Network, Child Only, Pediatric Dental Health Insurance Plan Variant 88582NY0270001-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 99.69% |
| First Tier Utilization | 100% |
| Formulary ID | NYF003 |
| HIOS Product ID | 88582NY027 |
| Import Date | 1/23/2023 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 81.98% |
| Issuer ID | 88582 |
| 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 | No |
| Network ID | NYN006 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Only |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 88582NY0270001-01 |
| Plan Level Exclusions | Yes |
| Plan Marketing Name | EmblemHealth, Gold, ST, INN, Prime Network, Child Only, Pediatric Dental |
| Plan Type | HMO |
| Plan Variant Marketing Name | EmblemHealth, Gold, ST, INN, Prime Network, Child Only, Pediatric Dental |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,540 |
| SBC Scenario, Having a Baby, Deductible | $600 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $346 |
| SBC Scenario, Having Diabetes, Copayment | $1,445 |
| SBC Scenario, Having Diabetes, Deductible | $600 |
| SBC Scenario, Having Diabetes, Limit | $55 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $7 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $865 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NYS002 |
| Source Name | SERFF |
| Specialist Requiring a Referral | Chiropractic services, Behavioral health services, Refractive eye exams from an optometrist, Diabetic eye exams from an ophthalmologist |
| Plan ID | 88582NY0270001 |
| 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 | 100.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $1200 per person | $1200 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $600 |
| 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 | $4750 per person | $9500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $4,750 |
| 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 EmblemHealth, Gold, ST, INN, Prime Network, Child Only, Pediatric Dental Health Insurance Plan, 88582NY0270001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about EmblemHealth, Gold, ST, INN, Prime Network, Child Only, Pediatric Dental, 88582NY0270001 Health Insurance Plan, 88582NY0270001
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Does EmblemHealth, Gold, ST, INN, Prime Network, Child Only, Pediatric Dental Health Insurance Plan, 88582NY0270001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (88582NY0270001) Health Insurance Plan, Variant (88582NY0270001-01) have Out Of Country Coverage?
Yes. Details: Emergency Only
Does (88582NY0270001) Health Insurance Plan, Variant (88582NY0270001-01) have Out of Service Area Coverage?
Yes. Details: Emergency Only
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