[MVP VT Plus] Gold 2 - 77566VT0050004 Health Insurance Plan
MVP Health Plan, Inc. health insurance plan with the Plan ID 77566VT0050004. The plan is called [MVP VT Plus] Gold 2.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.99% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.01% 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 81.47% (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 18.53% 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 | 77566VT0050004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Vermont | ||||||||||||||||||
| Health Insurance Issuer | MVP Health Plan, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 77566VT0050004-01 | ||||||||||||||||||
| Provider Network(s) | ['VTN001'] | ||||||||||||||||||
| 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 |
[MVP VT Plus] Gold 2 Health Insurance Plan Variant 77566VT0050004-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.814665511 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Maximum Out of Pocket for Drug EHB Benefits, Combined In/Out Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Drug EHB Benefits, Combined In/Out Network, Individual | Not Applicable |
| 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 | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $350 per person | $700 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $350 |
| Drug EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Drug EHB Benefits, In Network (Tier 1), Individual | $1,400 |
| Maximum Out of Pocket for Drug EHB Benefits, In Network (Tier 2), Individual | $1400 per person | $2800 per group |
| Maximum Out of Pocket for Drug EHB Benefits, Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Drug EHB Benefits, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| First Tier Utilization | 100% |
| Formulary ID | VTF001 |
| HIOS Product ID | 77566VT005 |
| 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? | No |
| Issuer Actuarial Value | 81.99% |
| Issuer ID | 77566 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | No |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out | Not Applicable |
| 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 | $850 per person | $1700 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $850 |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family | $6600 per person | $13200 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $6,600 |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | VTN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | All |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 77566VT0050004-01 |
| Plan Level Exclusions | No |
| Plan Marketing Name | [MVP VT Plus] Gold 2 |
| Plan Type | HMO |
| Plan Variant Marketing Name | [MVP VT Plus] Gold 2 |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $1,800 |
| SBC Scenario, Having a Baby, Copayment | $100 |
| SBC Scenario, Having a Baby, Deductible | $850 |
| SBC Scenario, Having a Baby, Limit | $70 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $800 |
| SBC Scenario, Having Diabetes, Deductible | $1,200 |
| SBC Scenario, Having Diabetes, Limit | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $10 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $850 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $10 |
| Service Area ID | VTS001 |
| Source Name | SERFF |
| Plan ID | 77566VT0050004 |
| State Code | VT |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of [MVP VT Plus] Gold 2 Health Insurance Plan, 77566VT0050004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about [MVP VT Plus] Gold 2, 77566VT0050004 Health Insurance Plan, 77566VT0050004
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Does [MVP VT Plus] Gold 2 Health Insurance Plan, 77566VT0050004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (77566VT0050004) Health Insurance Plan, Variant (77566VT0050004-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (77566VT0050004) Health Insurance Plan, Variant (77566VT0050004-01) have Out of Service Area Coverage?
Yes. Details: All
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