HSA Qualified 1500 Gold - 56707OR1150019 Health Insurance Plan
Providence Health Plan health insurance plan with the Plan ID 56707OR1150019. The plan is called HSA Qualified 1500 Gold.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 79.30% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 20.70% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.43% (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 20.57% 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 | 56707OR1150019 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Oregon | ||||||||||||||||||
| Health Insurance Issuer | Providence Health Plan | ||||||||||||||||||
| Health Insurance Plan Variant | 56707OR1150019-01 | ||||||||||||||||||
| Provider Network(s) | ['ORN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 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, 30 Apr 2024 06:06 GMT |
HSA Qualified 1500 Gold Health Insurance Plan Variant 56707OR1150019-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.794269706 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol |
| First Tier Utilization | 100% |
| Formulary ID | ORF007 |
| HIOS Product ID | 56707OR115 |
| HSA/HRA Employer Contribution | No |
| Import Date | 1/23/2023 |
| HSA Eligible | Yes |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 79.30% |
| Issuer ID | 56707 |
| 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 | ORN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Out of Network Benefits Apply |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | National Network and Out of Network Benefits Apply |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 56707OR1150019-01 |
| Plan Marketing Name | HSA Qualified 1500 Gold |
| Plan Type | PPO |
| Plan Variant Marketing Name | HSA Qualified 1500 Gold |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,200 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $800 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $1,500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ORS001 |
| Source Name | SERFF |
| Plan ID | 56707OR1150019 |
| State Code | OR |
| 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 | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $1500 per person | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| TEHBDedOutofNetFamily | $3000 per person | $6000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $3,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $6000 per person | $12000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $12000 per person | $24000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $12,000 |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of HSA Qualified 1500 Gold Health Insurance Plan, 56707OR1150019
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about HSA Qualified 1500 Gold, 56707OR1150019 Health Insurance Plan, 56707OR1150019
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Does HSA Qualified 1500 Gold Health Insurance Plan, 56707OR1150019 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (56707OR1150019) Health Insurance Plan, Variant (56707OR1150019-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol
Does (56707OR1150019) Health Insurance Plan, Variant (56707OR1150019-01) have Out Of Country Coverage?
Yes. Details: Out of Network Benefits Apply
Does (56707OR1150019) Health Insurance Plan, Variant (56707OR1150019-01) have Out of Service Area Coverage?
Yes. Details: National Network and Out of Network Benefits Apply
Does (56707OR1150019) Health Insurance Plan, Variant (56707OR1150019-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol
Does HSA Qualified 1500 Gold Health Insurance Plan, Variant (56707OR1150019-01) offer Disease Management Programs for Asthma?
Yes, the HSA Qualified 1500 Gold Health Insurance Plan Variant
56707OR1150019-01 offers Disease
Management Program for Asthma.
Does HSA Qualified 1500 Gold Health Insurance Plan, Variant (56707OR1150019-01) offer Disease Management Programs for Heart disease?
Yes, the HSA Qualified 1500 Gold Health Insurance Plan Variant
56707OR1150019-01 offers Disease
Management Program for Heart disease.
Does HSA Qualified 1500 Gold Health Insurance Plan, Variant (56707OR1150019-01) offer Disease Management Programs for Depression?
Yes, the HSA Qualified 1500 Gold Health Insurance Plan Variant
56707OR1150019-01 offers Disease
Management Program for Depression.
Does HSA Qualified 1500 Gold Health Insurance Plan, Variant (56707OR1150019-01) offer Disease Management Programs for Diabetes?
Yes, the HSA Qualified 1500 Gold Health Insurance Plan Variant
56707OR1150019-01 offers Disease
Management Program for Diabetes.
Does HSA Qualified 1500 Gold Health Insurance Plan, Variant (56707OR1150019-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the HSA Qualified 1500 Gold Health Insurance Plan Variant
56707OR1150019-01 offers Disease
Management Program for High blood pressure & high cholesterol.
Does HSA Qualified 1500 Gold Health Insurance Plan, Variant (56707OR1150019-01) offer Disease Management Programs for Low back pain?
Yes, the HSA Qualified 1500 Gold Health Insurance Plan Variant
56707OR1150019-01 offers Disease
Management Program for Low back pain.
Does HSA Qualified 1500 Gold Health Insurance Plan, Variant (56707OR1150019-01) offer Disease Management Programs for Pregnancy?
Yes, the HSA Qualified 1500 Gold Health Insurance Plan Variant
56707OR1150019-01 offers Disease
Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Tue, 30 Apr 2024 06:06 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