Fidelis Care Catastrophic, Catastrophic, ST, INN, Fidelis Care HBX Network, Pediatric Dental, 3 Free PCP Visits, Free Telemedicine - 25303NY0090001 Health Insurance Plan
New York Quality Healthcare Corporation health insurance plan with the Plan ID 25303NY0090001. The plan is called Fidelis Care Catastrophic, Catastrophic, ST, INN, Fidelis Care HBX Network, Pediatric Dental, 3 Free PCP Visits, Free Telemedicine.
| Health Insurance Plan ID | 25303NY0090001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | New York Quality Healthcare Corporation | ||||||||||||||||||
| Health Insurance Plan Variant | 25303NY0090001-01 | ||||||||||||||||||
| Provider Network(s) | ['NYN001'] | ||||||||||||||||||
| 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 |
Fidelis Care Catastrophic, Catastrophic, ST, INN, Fidelis Care HBX Network, Pediatric Dental, 3 Free PCP Visits, Free Telemedicine Health Insurance Plan Variant 25303NY0090001-01 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 | 99.57% |
| First Tier Utilization | 100% |
| Formulary ID | NYF004 |
| HIOS Product ID | 25303NY009 |
| Import Date | 1/23/2023 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 25303 |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Catastrophic |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | NYN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 25303NY0090001-01 |
| Plan Marketing Name | Fidelis Care Catastrophic, Catastrophic, ST, INN, Fidelis Care HBX Network, Pediatric Dental, 3 Free PCP Visits, Free Telemedicine |
| Plan Type | HMO |
| Plan Variant Marketing Name | Fidelis Care Catastrophic, Catastrophic, ST, INN, Fidelis Care HBX Network, Pediatric Dental, 3 Free PCP Visits, Free Telemedicine |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $9,100 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,200 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NYS001 |
| Source Name | SERFF |
| Plan ID | 25303NY0090001 |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $8700 per person | $17400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $8,700 |
| 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 | $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 Fidelis Care Catastrophic, Catastrophic, ST, INN, Fidelis Care HBX Network, Pediatric Dental, 3 Free PCP Visits, Free Telemedicine Health Insurance Plan, 25303NY0090001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Fidelis Care Catastrophic, Catastrophic, ST, INN, Fidelis Care HBX Network, Pediatric Dental, 3 Free PCP Visits, Free Telemedicine, 25303NY0090001 Health Insurance Plan, 25303NY0090001
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Does Fidelis Care Catastrophic, Catastrophic, ST, INN, Fidelis Care HBX Network, Pediatric Dental, 3 Free PCP Visits, Free Telemedicine Health Insurance Plan, 25303NY0090001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (25303NY0090001) Health Insurance Plan, Variant (25303NY0090001-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (25303NY0090001) Health Insurance Plan, Variant (25303NY0090001-01) have Out of Service Area Coverage?
No, unfortunately there
is no Out of Service Area Coverage for this Health Insurance
Plan (variant of plan).
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