Gold Simple PPO 0/0/25 - 45127PA0020026 Health Insurance Plan
Capital Advantage Assurance Company health insurance plan with the Plan ID 45127PA0020026. The plan is called Gold Simple PPO 0/0/25.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.77% (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 19.23% 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 | 45127PA0020026 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Pennsylvania | ||||||||||||||||||
| Health Insurance Issuer | Capital Advantage Assurance Company | ||||||||||||||||||
| Health Insurance Plan Variant | 45127PA0020026-01 | ||||||||||||||||||
| Provider Network(s) | ['PAN006'] | ||||||||||||||||||
| 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 | Standard On Exchange Plan - 45127PA0020026-01 |
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| Last Plan Update Date | Mon, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Gold Simple PPO 0/0/25 Health Insurance Plan Variant 45127PA0020026-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.807735487 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 100% |
| First Tier Utilization | 40% |
| Formulary ID | PAF008 |
| HIOS Product ID | 45127PA002 |
| Import Date | 1/23/2023 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 45127 |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | Yes |
| National Network | Yes |
| Network ID | PAN006 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Out of Country services are covered in accordance with your benefit contract. Certain services may not be covered. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Out of Service Area services are covered in accordance with your benefit contract. Certain services may not be covered. |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 45127PA0020026-01 |
| Plan Marketing Name | Gold Simple PPO 0/0/25 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Gold Simple PPO 0/0/25 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $4,100 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,400 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $30 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,000 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 60% |
| Service Area ID | PAS007 |
| Source Name | SERFF |
| Specialty Drug Maximum Coinsurance | $250 |
| Plan ID | 45127PA0020026 |
| State Code | PA |
| 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 | $0 per person | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 0.00% |
| 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 | $5000 per person | $10000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $5,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $8550 per person | $17100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,550 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family | $8550 per person | $17100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $8,550 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $10000 per person | $20000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $10,000 |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Gold Simple PPO 0/0/25 Health Insurance Plan, 45127PA0020026
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Gold Simple PPO 0/0/25, 45127PA0020026 Health Insurance Plan, 45127PA0020026
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Does Gold Simple PPO 0/0/25 Health Insurance Plan, 45127PA0020026 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (45127PA0020026) Health Insurance Plan, Variant (45127PA0020026-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy
Does (45127PA0020026) Health Insurance Plan, Variant (45127PA0020026-01) have Out Of Country Coverage?
Yes. Details: Out of Country services are covered in accordance with your benefit contract. Certain services may not be covered.
Does (45127PA0020026) Health Insurance Plan, Variant (45127PA0020026-01) have Out of Service Area Coverage?
Yes. Details: Out of Service Area services are covered in accordance with your benefit contract. Certain services may not be covered.
Does (45127PA0020026) Health Insurance Plan, Variant (45127PA0020026-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy
Does Gold Simple PPO 0/0/25 Health Insurance Plan, Variant (45127PA0020026-01) offer Disease Management Programs for Asthma?
Yes, the Gold Simple PPO 0/0/25 Health Insurance Plan Variant
45127PA0020026-01 offers Disease
Management Program for Asthma.
Does Gold Simple PPO 0/0/25 Health Insurance Plan, Variant (45127PA0020026-01) offer Disease Management Programs for Heart disease?
Yes, the Gold Simple PPO 0/0/25 Health Insurance Plan Variant
45127PA0020026-01 offers Disease
Management Program for Heart disease.
Does Gold Simple PPO 0/0/25 Health Insurance Plan, Variant (45127PA0020026-01) offer Disease Management Programs for Depression?
Yes, the Gold Simple PPO 0/0/25 Health Insurance Plan Variant
45127PA0020026-01 offers Disease
Management Program for Depression.
Does Gold Simple PPO 0/0/25 Health Insurance Plan, Variant (45127PA0020026-01) offer Disease Management Programs for Diabetes?
Yes, the Gold Simple PPO 0/0/25 Health Insurance Plan Variant
45127PA0020026-01 offers Disease
Management Program for Diabetes.
Does Gold Simple PPO 0/0/25 Health Insurance Plan, Variant (45127PA0020026-01) offer Disease Management Programs for Pregnancy?
Yes, the Gold Simple PPO 0/0/25 Health Insurance Plan Variant
45127PA0020026-01 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