HMO Triple Zero Copayment 224, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP - 94788NY0260103 Health Insurance Plan
CDPHP health insurance plan with the Plan ID 94788NY0260103. The plan is called HMO Triple Zero Copayment 224, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.80% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.20% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 94788NY0260103 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | CDPHP | ||||||||||||||||||
| Health Insurance Plan Variant | 94788NY0260103-01 | ||||||||||||||||||
| 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 |
HMO Triple Zero Copayment 224, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP Health Insurance Plan Variant 94788NY0260103-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2023 |
| Child-Only Offering | Allows Adult-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 | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, In Network (Tier 1), Individual | Not Applicable |
| 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 |
| First Tier Utilization | 100% |
| Formulary ID | NYF003 |
| HIOS Product ID | 94788NY026 |
| 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? | Yes |
| Issuer Actuarial Value | 81.80% |
| Issuer ID | 94788 |
| 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 | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | NYN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Only |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 94788NY0260103-01 |
| Plan Marketing Name | HMO Triple Zero Copayment 224, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP |
| Plan Type | HMO |
| Plan Variant Marketing Name | HMO Triple Zero Copayment 224, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $2,500 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $864 |
| SBC Scenario, Having Diabetes, Copayment | $1,950 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $55 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $18 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,700 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NYS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All |
| Plan ID | 94788NY0260103 |
| 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 | $8700 per person | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| 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 | Yes |
Copay & Coinsurance of HMO Triple Zero Copayment 224, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP Health Insurance Plan, 94788NY0260103
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about HMO Triple Zero Copayment 224, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP, 94788NY0260103 Health Insurance Plan, 94788NY0260103
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Does HMO Triple Zero Copayment 224, Gold, NS, INN, Dep29, Adult Vision, Lasik, Wellness, DP Health Insurance Plan, 94788NY0260103 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (94788NY0260103) Health Insurance Plan, Variant (94788NY0260103-01) have Out Of Country Coverage?
Yes. Details: Emergency Only
Does (94788NY0260103) Health Insurance Plan, Variant (94788NY0260103-01) have Out of Service Area Coverage?
Yes. Details: Emergency Only
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