Navigator Bronze 8700 - 23603MT0290015 Health Insurance Plan
PacificSource Health Plans health insurance plan with the Plan ID 23603MT0290015. The plan is called Navigator Bronze 8700.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 61.06% (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 38.94% 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 | 23603MT0290015 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Montana | ||||||||||||||||||
| Health Insurance Issuer | PacificSource Health Plans | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 23603MT0290015-00 | ||||||||||||||||||
| Provider Network(s) | ['MTN001'] | ||||||||||||||||||
| 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 | Standard Off Exchange Plan - 23603MT0290015-00 Standard On Exchange Plan - 23603MT0290015-01 |
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| Last Plan Update Date | Wed, 18 Aug 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Navigator Bronze 8700 Health Insurance Plan Variant 23603MT0290015-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.610579081 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2022 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze Off Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 0.9999 |
| First Tier Utilization | 100% |
| Formulary ID | MTF001 |
| Formulary URL | URL |
| HIOS Product ID | 23603MT029 |
| Import Date | 8/18/2021 20:00 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 23603 |
| Issuer Marketplace Marketing Name | PacificSource Health Plans |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Bronze |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | MTN001 |
| 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 | Non-Participating Providers |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan ID (Standard Component ID with Variant) | 23603MT0290015-00 |
| Plan Marketing Name | Navigator Bronze 8700 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Navigator Bronze 8700 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $8,700 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,400 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MTS001 |
| Source Name | SERFF |
| Plan ID | 23603MT0290015 |
| State Code | MT |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person 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 Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $17400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $8700 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $8,700 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $34800 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $17400 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $17,400 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| 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 Group | $50000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $25000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $25,000 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Navigator Bronze 8700 Health Insurance Plan, 23603MT0290015
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Navigator Bronze 8700, 23603MT0290015 Health Insurance Plan, 23603MT0290015
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Does Navigator Bronze 8700 Health Insurance Plan, 23603MT0290015 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (23603MT0290015) Health Insurance Plan, Variant (23603MT0290015-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy
Does (23603MT0290015) Health Insurance Plan, Variant (23603MT0290015-00) have Out Of Country Coverage?
Yes. Details: Emergency Care Only
Does (23603MT0290015) Health Insurance Plan, Variant (23603MT0290015-00) have Out of Service Area Coverage?
Yes. Details: Non-Participating Providers
Does (23603MT0290015) Health Insurance Plan, Variant (23603MT0290015-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy
Does Navigator Bronze 8700 Health Insurance Plan, Variant (23603MT0290015-00) offer Disease Management Programs for Asthma?
Yes, the Navigator Bronze 8700 Health Insurance Plan Variant
23603MT0290015-00 offers Disease
Management Program for Asthma.
Does Navigator Bronze 8700 Health Insurance Plan, Variant (23603MT0290015-00) offer Disease Management Programs for Heart disease?
Yes, the Navigator Bronze 8700 Health Insurance Plan Variant
23603MT0290015-00 offers Disease
Management Program for Heart disease.
Does Navigator Bronze 8700 Health Insurance Plan, Variant (23603MT0290015-00) offer Disease Management Programs for Diabetes?
Yes, the Navigator Bronze 8700 Health Insurance Plan Variant
23603MT0290015-00 offers Disease
Management Program for Diabetes.
Does Navigator Bronze 8700 Health Insurance Plan, Variant (23603MT0290015-00) offer Disease Management Programs for Pregnancy?
Yes, the Navigator Bronze 8700 Health Insurance Plan Variant
23603MT0290015-00 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