EmblemHealth PPO-N, Gold, OON, Bridge Program non-gated, Dep25, 3 Free PCP, No Deductible All Drugs, Free Telemedicine and Acupuncture, Pediatric Vision, Pediatric Dental, DP - 20984NY0480001 Health Insurance Plan
EmblemHealth Insurance Company health insurance plan with the Plan ID 20984NY0480001. The plan is called EmblemHealth PPO-N, Gold, OON, Bridge Program non-gated, Dep25, 3 Free PCP, No Deductible All Drugs, Free Telemedicine and Acupuncture, Pediatric Vision, Pediatric Dental, DP.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 79.67% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 20.33% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 20984NY0480001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | EmblemHealth Insurance Company | ||||||||||||||||||
| Health Insurance Plan Variant | 20984NY0480001-01 | ||||||||||||||||||
| Provider Network(s) | ['NYN007'] | ||||||||||||||||||
| 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 |
EmblemHealth PPO-N, Gold, OON, Bridge Program non-gated, Dep25, 3 Free PCP, No Deductible All Drugs, Free Telemedicine and Acupuncture, Pediatric Vision, Pediatric Dental, DP Health Insurance Plan Variant 20984NY0480001-01 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| 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 | 100.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 |
| First Tier Utilization | 100% |
| Formulary ID | NYF002 |
| HIOS Product ID | 20984NY048 |
| HSA/HRA Employer Contribution | No |
| Import Date | 1/23/2023 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 79.67% |
| Issuer ID | 20984 |
| 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 | 100.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $1500 per person | $3000 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Medical EHB Deductible, Out of Network, Family | $3800 per person | $7600 per group |
| Medical EHB Deductible, Out of Network, Individual | $3,800 |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | NYN007 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emegency 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) | 20984NY0480001-01 |
| Plan Level Exclusions | No |
| Plan Marketing Name | EmblemHealth PPO-N, Gold, OON, Bridge Program non-gated, Dep25, 3 Free PCP, No Deductible All Drugs, Free Telemedicine and Acupuncture, Pediatric Vision, Pediatric Dental, DP |
| Plan Type | PPO |
| Plan Variant Marketing Name | EmblemHealth PPO-N, Gold, OON, Bridge Program non-gated, Dep25, 3 Free PCP, No Deductible All Drugs, Free Telemedicine and Acupuncture, Pediatric Vision, Pediatric Dental, DP |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,280 |
| SBC Scenario, Having a Baby, Copayment | $720 |
| SBC Scenario, Having a Baby, Deductible | $1,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $346 |
| SBC Scenario, Having Diabetes, Copayment | $1,375 |
| SBC Scenario, Having Diabetes, Deductible | $1,000 |
| SBC Scenario, Having Diabetes, Limit | $55 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $245 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $920 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $763 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NYS001 |
| Source Name | SERFF |
| Plan ID | 20984NY0480001 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $6200 per person | $12400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $8000 per person | $16000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $8,000 |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of EmblemHealth PPO-N, Gold, OON, Bridge Program non-gated, Dep25, 3 Free PCP, No Deductible All Drugs, Free Telemedicine and Acupuncture, Pediatric Vision, Pediatric Dental, DP Health Insurance Plan, 20984NY0480001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about EmblemHealth PPO-N, Gold, OON, Bridge Program non-gated, Dep25, 3 Free PCP, No Deductible All Drugs, Free Telemedicine and Acupuncture, Pediatric Vision, Pediatric Dental, DP, 20984NY0480001 Health Insurance Plan, 20984NY0480001
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Does EmblemHealth PPO-N, Gold, OON, Bridge Program non-gated, Dep25, 3 Free PCP, No Deductible All Drugs, Free Telemedicine and Acupuncture, Pediatric Vision, Pediatric Dental, DP Health Insurance Plan, 20984NY0480001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (20984NY0480001) Health Insurance Plan, Variant (20984NY0480001-01) have Out Of Country Coverage?
Yes. Details: Emegency Only
Does (20984NY0480001) Health Insurance Plan, Variant (20984NY0480001-01) 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