ENGAGE SG GOLD ID - 38128ID0150001 Health Insurance Plan
Mountain Health Cooperative health insurance plan with the Plan ID 38128ID0150001. The plan is called ENGAGE SG GOLD ID.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.98% (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 19.02% 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 | 38128ID0150001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Idaho | ||||||||||||||||||
| Health Insurance Issuer | Mountain Health Cooperative | ||||||||||||||||||
| Health Insurance Plan Variant | 38128ID0150001-01 | ||||||||||||||||||
| Provider Network(s) | ['IDN002'] | ||||||||||||||||||
| 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 |
ENGAGE SG GOLD ID Health Insurance Plan Variant 38128ID0150001-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.809751802 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | Yes |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Diabetes |
| First Tier Utilization | 100% |
| Formulary ID | IDF003 |
| HIOS Product ID | 38128ID015 |
| 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 ID | 38128 |
| 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 | No |
| National Network | Yes |
| Network ID | IDN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergent Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergent Only |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 38128ID0150001-01 |
| Plan Marketing Name | ENGAGE SG GOLD ID |
| Plan Type | POS |
| Plan Variant Marketing Name | ENGAGE SG GOLD ID |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,900 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $5,300 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,300 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,700 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | IDS004 |
| Source Name | SERFF |
| Plan ID | 38128ID0150001 |
| State Code | ID |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family | $19500 per person | $39000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $19,500 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family | $3000 per person | $6000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $3,000 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $1000 per person | $2000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,000 |
| TEHBDedOutofNetFamily | $2000 per person | $4000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $2,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $6500 per person | $13000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $13000 per person | $26000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $13,000 |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of ENGAGE SG GOLD ID Health Insurance Plan, 38128ID0150001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about ENGAGE SG GOLD ID, 38128ID0150001 Health Insurance Plan, 38128ID0150001
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Does ENGAGE SG GOLD ID Health Insurance Plan, 38128ID0150001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (38128ID0150001) Health Insurance Plan, Variant (38128ID0150001-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Diabetes
Does (38128ID0150001) Health Insurance Plan, Variant (38128ID0150001-01) have Out Of Country Coverage?
Yes. Details: Emergent Only
Does (38128ID0150001) Health Insurance Plan, Variant (38128ID0150001-01) have Out of Service Area Coverage?
Yes. Details: Emergent Only
Does (38128ID0150001) Health Insurance Plan, Variant (38128ID0150001-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Diabetes
Does ENGAGE SG GOLD ID Health Insurance Plan, Variant (38128ID0150001-01) offer Disease Management Programs for Asthma?
Yes, the ENGAGE SG GOLD ID Health Insurance Plan Variant
38128ID0150001-01 offers Disease
Management Program for Asthma.
Does ENGAGE SG GOLD ID Health Insurance Plan, Variant (38128ID0150001-01) offer Disease Management Programs for Diabetes?
Yes, the ENGAGE SG GOLD ID Health Insurance Plan Variant
38128ID0150001-01 offers Disease
Management Program for Diabetes.
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