OMNIA Gold - 91661NJ2350004 Health Insurance Plan
Horizon Healthcare Services, Inc. health insurance plan with the Plan ID 91661NJ2350004. The plan is called OMNIA Gold.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.58% (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 20.42% 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 | 91661NJ2350004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | New Jersey | ||||||||||||||||||
| Health Insurance Issuer | Horizon Healthcare Services, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 91661NJ2350004-01 | ||||||||||||||||||
| Provider Network(s) | ['NJN004'] | ||||||||||||||||||
| 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 |
OMNIA Gold Health Insurance Plan Variant 91661NJ2350004-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.795770185 |
| 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 | $250 per person | $500 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $250 |
| Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 2), Family | $250 per person | $500 per group |
| Drug EHB Deductible, In Network (Tier 2), Individual | $250 |
| 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, Pregnancy |
| First Tier Utilization | 82.90 |
| Formulary ID | NJF008 |
| HIOS Product ID | 91661NJ235 |
| HSA/HRA Employer Contribution | No |
| Import Date | 1/23/2023 |
| Inpatient Copayment Maximum Days | 5 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 91661 |
| 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 | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $900 per person | $1800 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $900 |
| Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 30.00% |
| Medical EHB Deductible, In Network (Tier 2), Family | $2500 per person | $5000 per group |
| Medical EHB Deductible, In Network (Tier 2), Individual | $2,500 |
| 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 | Yes |
| National Network | No |
| Network ID | NJN004 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Only to true medical emergencies and accidental injuries. |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 91661NJ2350004-01 |
| Plan Marketing Name | OMNIA Gold |
| Plan Type | EPO |
| Plan Variant Marketing Name | OMNIA Gold |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $500 |
| SBC Scenario, Having a Baby, Deductible | $900 |
| 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 | $250 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $900 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 17.10 |
| Service Area ID | NJS002 |
| Source Name | SERFF |
| Plan ID | 91661NJ2350004 |
| State Code | NJ |
| 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 | $7500 per person | $15000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family | $9000 per person | $18000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,000 |
| 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 | No |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of OMNIA Gold Health Insurance Plan, 91661NJ2350004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about OMNIA Gold, 91661NJ2350004 Health Insurance Plan, 91661NJ2350004
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Does OMNIA Gold Health Insurance Plan, 91661NJ2350004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (91661NJ2350004) Health Insurance Plan, Variant (91661NJ2350004-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy
Does (91661NJ2350004) Health Insurance Plan, Variant (91661NJ2350004-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (91661NJ2350004) Health Insurance Plan, Variant (91661NJ2350004-01) have Out of Service Area Coverage?
Yes. Details: Only to true medical emergencies and accidental injuries.
Does (91661NJ2350004) Health Insurance Plan, Variant (91661NJ2350004-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy
Does OMNIA Gold Health Insurance Plan, Variant (91661NJ2350004-01) offer Disease Management Programs for Asthma?
Yes, the OMNIA Gold Health Insurance Plan Variant
91661NJ2350004-01 offers Disease
Management Program for Asthma.
Does OMNIA Gold Health Insurance Plan, Variant (91661NJ2350004-01) offer Disease Management Programs for Heart disease?
Yes, the OMNIA Gold Health Insurance Plan Variant
91661NJ2350004-01 offers Disease
Management Program for Heart disease.
Does OMNIA Gold Health Insurance Plan, Variant (91661NJ2350004-01) offer Disease Management Programs for Depression?
Yes, the OMNIA Gold Health Insurance Plan Variant
91661NJ2350004-01 offers Disease
Management Program for Depression.
Does OMNIA Gold Health Insurance Plan, Variant (91661NJ2350004-01) offer Disease Management Programs for Diabetes?
Yes, the OMNIA Gold Health Insurance Plan Variant
91661NJ2350004-01 offers Disease
Management Program for Diabetes.
Does OMNIA Gold Health Insurance Plan, Variant (91661NJ2350004-01) offer Disease Management Programs for Pregnancy?
Yes, the OMNIA Gold Health Insurance Plan Variant
91661NJ2350004-01 offers Disease
Management Program for Pregnancy.
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