Group HMO HDHP/HSA Gold 4 w/Gym - 57173NM0260004 Health Insurance Plan
Presbyterian Health Plan health insurance plan with the Plan ID 57173NM0260004. The plan is called Group HMO HDHP/HSA Gold 4 w/Gym.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.33% (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 20.67% 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 | 57173NM0260004 | ||||||||||||||||||
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| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | New Mexico | ||||||||||||||||||
| Health Insurance Issuer | Presbyterian Health Plan | ||||||||||||||||||
| Health Insurance Plan Variant | 57173NM0260004-01 | ||||||||||||||||||
| Provider Network(s) | ['NMN004'] | ||||||||||||||||||
| 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 | Tue, 09 May 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Group HMO HDHP/HSA Gold 4 w/Gym On Health Insurance Plan Variant 57173NM0260004-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.793287587 |
| 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 |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol |
| First Tier Utilization | 100% |
| Formulary ID | NMF007 |
| HIOS Product ID | 57173NM026 |
| HSA/HRA Employer Contribution | No |
| Import Date | 5/9/2023 |
| HSA Eligible | Yes |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 57173 |
| 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 | NMN004 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency and Non-emergency when Prior Authorization is obtained |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency and Non-emergency when Prior Authorization is obtained |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 57173NM0260004-01 |
| Plan Marketing Name | Group HMO HDHP/HSA Gold 4 w/Gym |
| Plan Type | HMO |
| Plan Variant Marketing Name | Group HMO HDHP/HSA Gold 4 w/Gym On |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $3,200 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $3,200 |
| 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 | NMS003 |
| Source Name | SERFF |
| Plan ID | 57173NM0260004 |
| State Code | NM |
| 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 | $3200 per person | $6400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,200 |
| 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 | $3200 per person | $6400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,200 |
| 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 | No |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Group HMO HDHP/HSA Gold 4 w/Gym Health Insurance Plan, 57173NM0260004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Group HMO HDHP/HSA Gold 4 w/Gym, 57173NM0260004 Health Insurance Plan, 57173NM0260004
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Does Group HMO HDHP/HSA Gold 4 w/Gym Health Insurance Plan, 57173NM0260004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (57173NM0260004) Health Insurance Plan, Variant (57173NM0260004-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol
Does (57173NM0260004) Health Insurance Plan, Variant (57173NM0260004-01) have Out Of Country Coverage?
Yes. Details: Emergency and Non-emergency when Prior Authorization is obtained
Does (57173NM0260004) Health Insurance Plan, Variant (57173NM0260004-01) have Out of Service Area Coverage?
Yes. Details: Emergency and Non-emergency when Prior Authorization is obtained
Does (57173NM0260004) Health Insurance Plan, Variant (57173NM0260004-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol
Does Group HMO HDHP/HSA Gold 4 w/Gym On Health Insurance Plan, Variant (57173NM0260004-01) offer Disease Management Programs for Asthma?
Yes, the Group HMO HDHP/HSA Gold 4 w/Gym On Health Insurance Plan Variant
57173NM0260004-01 offers Disease
Management Program for Asthma.
Does Group HMO HDHP/HSA Gold 4 w/Gym On Health Insurance Plan, Variant (57173NM0260004-01) offer Disease Management Programs for Heart disease?
Yes, the Group HMO HDHP/HSA Gold 4 w/Gym On Health Insurance Plan Variant
57173NM0260004-01 offers Disease
Management Program for Heart disease.
Does Group HMO HDHP/HSA Gold 4 w/Gym On Health Insurance Plan, Variant (57173NM0260004-01) offer Disease Management Programs for Diabetes?
Yes, the Group HMO HDHP/HSA Gold 4 w/Gym On Health Insurance Plan Variant
57173NM0260004-01 offers Disease
Management Program for Diabetes.
Does Group HMO HDHP/HSA Gold 4 w/Gym On Health Insurance Plan, Variant (57173NM0260004-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Group HMO HDHP/HSA Gold 4 w/Gym On Health Insurance Plan Variant
57173NM0260004-01 offers Disease
Management Program for High blood pressure & high cholesterol.
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