EmblemHealth Virtual EPO-N, Gold, INN, Bridge Program non-gated with Virtual Tier, Dep29, Free Acupuncture and Telemedicine, Pediatric Vision, Pediatric Dental, DP - 20984NY0650001 Health Insurance Plan
EmblemHealth Insurance Company health insurance plan with the Plan ID 20984NY0650001. The plan is called EmblemHealth Virtual EPO-N, Gold, INN, Bridge Program non-gated with Virtual Tier, Dep29, Free Acupuncture and Telemedicine, Pediatric Vision, Pediatric Dental, DP.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 79.21% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 20.79% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 20984NY0650001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | EmblemHealth Insurance Company | ||||||||||||||||||
| Health Insurance Plan Variant | 20984NY0650001-01 | ||||||||||||||||||
| 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 Virtual EPO-N, Gold, INN, Bridge Program non-gated with Virtual Tier, Dep29, Free Acupuncture and Telemedicine, Pediatric Vision, Pediatric Dental, DP Health Insurance Plan Variant 20984NY0650001-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| Dental Only Plan | No |
| First Tier Utilization | 20% |
| Formulary ID | NYF003 |
| HIOS Product ID | 20984NY065 |
| 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 | 79.21% |
| Issuer ID | 20984 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | Yes |
| 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) | 20984NY0650001-01 |
| Plan Level Exclusions | No |
| Plan Marketing Name | EmblemHealth Virtual EPO-N, Gold, INN, Bridge Program non-gated with Virtual Tier, Dep29, Free Acupuncture and Telemedicine, Pediatric Vision, Pediatric Dental, DP |
| Plan Type | EPO |
| Plan Variant Marketing Name | EmblemHealth Virtual EPO-N, Gold, INN, Bridge Program non-gated with Virtual Tier, Dep29, Free Acupuncture and Telemedicine, 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 |
| Second Tier Utilization | 80% |
| Service Area ID | NYS001 |
| Source Name | SERFF |
| Plan ID | 20984NY0650001 |
| 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 | $750 per person | $1500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $750 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 100.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family | $0 per person | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
| 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 | $8000 per person | $16000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family | $8000 per person | $16000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $8,000 |
| 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 | No |
Copay & Coinsurance of EmblemHealth Virtual EPO-N, Gold, INN, Bridge Program non-gated with Virtual Tier, Dep29, Free Acupuncture and Telemedicine, Pediatric Vision, Pediatric Dental, DP Health Insurance Plan, 20984NY0650001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about EmblemHealth Virtual EPO-N, Gold, INN, Bridge Program non-gated with Virtual Tier, Dep29, Free Acupuncture and Telemedicine, Pediatric Vision, Pediatric Dental, DP, 20984NY0650001 Health Insurance Plan, 20984NY0650001
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Does EmblemHealth Virtual EPO-N, Gold, INN, Bridge Program non-gated with Virtual Tier, Dep29, Free Acupuncture and Telemedicine, Pediatric Vision, Pediatric Dental, DP Health Insurance Plan, 20984NY0650001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (20984NY0650001) Health Insurance Plan, Variant (20984NY0650001-01) have Out Of Country Coverage?
Yes. Details: Emegency Only
Does (20984NY0650001) Health Insurance Plan, Variant (20984NY0650001-01) 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