Kaiser Foundation Healthplan of the NW health insurance plan with the Plan ID 71287OR0440049. The plan is called KP OR Silver 4000/45 3T POS w/Massage.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.42% (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 29.58% 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 | 71287OR0440049 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Oregon | ||||||||||||||||||
Health Insurance Issuer | Kaiser Foundation Healthplan of the NW | ||||||||||||||||||
Health Insurance Plan Variant | 71287OR0440049-01 | ||||||||||||||||||
Provider Network(s) | ['ORN003'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 21 May 2024 06:25 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, 21 May 2024 06:25 GMT |
Plan Attribute | Value |
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AV Calculator Output Number | 0.704191212 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | Yes |
CSR Variation Type | Standard Silver 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 | 75% |
Formulary ID | ORF019 |
HIOS Product ID | 71287OR044 |
HSA/HRA Employer Contribution | No |
Import Date | 1/23/2023 |
HSA Eligible | No |
IsItANewPlan | New |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | Yes |
Issuer ID | 71287 |
Market Coverage | SHOP (Small Group) |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Silver |
Multiple In Network Tiers | Yes |
National Network | Yes |
Network ID | ORN003 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Emergency medical conditions including prescription drugs and other covered services, refer to the EOC |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Emergency medical conditions including prescription drugs and other covered services, refer to the EOC |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 71287OR0440049-01 |
Plan Marketing Name | KP OR Silver 4000/45 3T POS w/Massage |
Plan Type | POS |
Plan Variant Marketing Name | KP OR Silver 4000/45 3T POS w/Massage |
QHP/Non QHP | On the Exchange |
SBC Scenario, Having a Baby, Coinsurance | $1,800 |
SBC Scenario, Having a Baby, Copayment | $300 |
SBC Scenario, Having a Baby, Deductible | $4,000 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $100 |
SBC Scenario, Having Diabetes, Copayment | $1,500 |
SBC Scenario, Having Diabetes, Deductible | $70 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $500 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,900 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Second Tier Utilization | 25% |
Service Area ID | ORS002 |
Source Name | SERFF |
Specialist Requiring a Referral | A referral is not required for Outpatient Services provided in the following departments: Cancer Counseling, Chemical Dependency Services, Mental Health Services, Obstetrics/Gynecology, Occupational Health, Opthalmology, and Optometry (routine eye exams), and Social Services. |
Plan ID | 71287OR0440049 |
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 | 40.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $4000 per person | $8000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,000 |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 45.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family | $6000 per person | $12000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $6,000 |
TEHBDedOutofNetFamily | $7000 per person | $14000 per group |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | $7,000 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $8900 per person | $17800 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,900 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family | $8900 per person | $17800 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $8,900 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $14000 per person | $28000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $14,000 |
Unique Plan Design | No |
Version Number | 1 |
Wellness Program Offered | Yes |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 21 May 2024 06:25 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