KP DC Standard Gold 500/25/20%/Vision - 94506DC0350032 Health Insurance Plan
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. health insurance plan with the Plan ID 94506DC0350032. The plan is called KP DC Standard Gold 500/25/20%/Vision.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.88% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.12% 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 81.88% (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 18.12% 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 | 94506DC0350032 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | District of Columbia | ||||||||||||||||||
| Health Insurance Issuer | Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 94506DC0350032-01 | ||||||||||||||||||
| Provider Network(s) | ['DCN002'] | ||||||||||||||||||
| 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 |
KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan Variant 94506DC0350032-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.818831585 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| 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 | $0 per person | per group not applicable |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Weight Loss Programs, Low Back Pain, High Blood Pressure & High Cholesterol |
| First Tier Utilization | 100% |
| Formulary ID | DCF006 |
| HIOS Product ID | 94506DC035 |
| HSA/HRA Employer Contribution | No |
| Import Date | 1/23/2023 |
| Inpatient Copayment Maximum Days | 5 |
| HSA Eligible | No |
| IsItANewPlan | New |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 81.88% |
| Issuer ID | 94506 |
| 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 | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $500 per person | $1000 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $500 |
| 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 | DCN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Care Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Care Only |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 94506DC0350032-01 |
| Plan Marketing Name | KP DC Standard Gold 500/25/20%/Vision |
| Plan Type | HMO |
| Plan Variant Marketing Name | KP DC Standard Gold 500/25/20%/Vision |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $600 |
| SBC Scenario, Having a Baby, Deductible | $500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,000 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $80 |
| 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 |
| Service Area ID | DCS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | Referrals are required for all Plan specialists with the exception of OB/GYN, Mental Health, Alcohol/Chemical Dependency, Routine Eye Exams. |
| Plan ID | 94506DC0350032 |
| State Code | DC |
| 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 | $5800 per person | $11600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,800 |
| 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 KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan, 94506DC0350032
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about KP DC Standard Gold 500/25/20%/Vision, 94506DC0350032 Health Insurance Plan, 94506DC0350032
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Does KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan, 94506DC0350032 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (94506DC0350032) Health Insurance Plan, Variant (94506DC0350032-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Weight Loss Programs, Low Back Pain, High Blood Pressure & High Cholesterol
Does (94506DC0350032) Health Insurance Plan, Variant (94506DC0350032-01) have Out Of Country Coverage?
Yes. Details: Emergency Care Only
Does (94506DC0350032) Health Insurance Plan, Variant (94506DC0350032-01) have Out of Service Area Coverage?
Yes. Details: Emergency Care Only
Does (94506DC0350032) Health Insurance Plan, Variant (94506DC0350032-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Weight Loss Programs, Low Back Pain, High Blood Pressure & High Cholesterol
Does KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan, Variant (94506DC0350032-01) offer Disease Management Programs for Asthma?
Yes, the KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan Variant
94506DC0350032-01 offers Disease
Management Program for Asthma.
Does KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan, Variant (94506DC0350032-01) offer Disease Management Programs for Heart disease?
Yes, the KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan Variant
94506DC0350032-01 offers Disease
Management Program for Heart disease.
Does KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan, Variant (94506DC0350032-01) offer Disease Management Programs for Depression?
Yes, the KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan Variant
94506DC0350032-01 offers Disease
Management Program for Depression.
Does KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan, Variant (94506DC0350032-01) offer Disease Management Programs for Diabetes?
Yes, the KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan Variant
94506DC0350032-01 offers Disease
Management Program for Diabetes.
Does KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan, Variant (94506DC0350032-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan Variant
94506DC0350032-01 offers Disease
Management Program for High blood pressure & high cholesterol.
Does KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan, Variant (94506DC0350032-01) offer Disease Management Programs for Low back pain?
Yes, the KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan Variant
94506DC0350032-01 offers Disease
Management Program for Low back pain.
Does KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan, Variant (94506DC0350032-01) offer Disease Management Programs for Pregnancy?
Yes, the KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan Variant
94506DC0350032-01 offers Disease
Management Program for Pregnancy.
Does KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan, Variant (94506DC0350032-01) offer Disease Management Programs for Weight loss programs?
Yes, the KP DC Standard Gold 500/25/20%/Vision Health Insurance Plan Variant
94506DC0350032-01 offers Disease
Management Program for Weight loss programs.
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