Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out - 44113NY0370039 Health Insurance Plan
Empire HealthChoice Assurance, Inc. health insurance plan with the Plan ID 44113NY0370039. The plan is called Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.97% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.03% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.84% (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 28.16% 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 | 44113NY0370039 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | Empire HealthChoice Assurance, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 44113NY0370039-01 | ||||||||||||||||||
| Provider Network(s) | ['NYN004'] | ||||||||||||||||||
| 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 |
Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out Health Insurance Plan Variant 44113NY0370039-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.718367051 |
| 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 | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $200 per person | $400 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $200 |
| 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 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pregnancy |
| First Tier Utilization | 100% |
| Formulary ID | NYF004 |
| HIOS Product ID | 44113NY037 |
| HSA/HRA Employer Contribution | No |
| Import Date | 1/23/2023 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 71.97% |
| Issuer ID | 44113 |
| 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 | 50.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $4550 per person | $9100 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $4,550 |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | NYN004 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Standard Bluecard PPO Network |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 44113NY0370039-01 |
| Plan Marketing Name | Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out |
| Plan Type | EPO |
| Plan Variant Marketing Name | Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,100 |
| SBC Scenario, Having a Baby, Copayment | $300 |
| SBC Scenario, Having a Baby, Deductible | $4,550 |
| SBC Scenario, Having a Baby, Limit | $2,700 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $2,000 |
| SBC Scenario, Having Diabetes, Deductible | $200 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,100 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NYS002 |
| Source Name | SERFF |
| Plan ID | 44113NY0370039 |
| 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 | $9100 per person | $18200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,100 |
| 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 Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out Health Insurance Plan, 44113NY0370039
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out, 44113NY0370039 Health Insurance Plan, 44113NY0370039
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Does Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out Health Insurance Plan, 44113NY0370039 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (44113NY0370039) Health Insurance Plan, Variant (44113NY0370039-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy
Does (44113NY0370039) Health Insurance Plan, Variant (44113NY0370039-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (44113NY0370039) Health Insurance Plan, Variant (44113NY0370039-01) have Out of Service Area Coverage?
Yes. Details: Standard Bluecard PPO Network
Does (44113NY0370039) Health Insurance Plan, Variant (44113NY0370039-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy
Does Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out Health Insurance Plan, Variant (44113NY0370039-01) offer Disease Management Programs for Asthma?
Yes, the Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out Health Insurance Plan Variant
44113NY0370039-01 offers Disease
Management Program for Asthma.
Does Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out Health Insurance Plan, Variant (44113NY0370039-01) offer Disease Management Programs for Heart disease?
Yes, the Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out Health Insurance Plan Variant
44113NY0370039-01 offers Disease
Management Program for Heart disease.
Does Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out Health Insurance Plan, Variant (44113NY0370039-01) offer Disease Management Programs for Depression?
Yes, the Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out Health Insurance Plan Variant
44113NY0370039-01 offers Disease
Management Program for Depression.
Does Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out Health Insurance Plan, Variant (44113NY0370039-01) offer Disease Management Programs for Diabetes?
Yes, the Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out Health Insurance Plan Variant
44113NY0370039-01 offers Disease
Management Program for Diabetes.
Does Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out Health Insurance Plan, Variant (44113NY0370039-01) offer Disease Management Programs for Pregnancy?
Yes, the Empire EPO 4550 50 9100 Silver INN Blue Access Dep 25 Wellness Pediatric Dental DP FP RE A Opt Out Health Insurance Plan Variant
44113NY0370039-01 offers Disease
Management Program for Pregnancy.
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