Select Plan Basic - 15614PA0010004 Health Insurance Plan
15614 health insurance plan with the Plan ID 15614PA0010004. The plan is called Select Plan Basic.
| Health Insurance Plan ID | 15614PA0010004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Pennsylvania | ||||||||||||||||||
| Health Insurance Issuer | 15614 | ||||||||||||||||||
| Health Insurance Plan Variant | 15614PA0010004-01 | ||||||||||||||||||
| Provider Network(s) | ['PAN001'] | ||||||||||||||||||
| 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 |
Select Plan Basic Health Insurance Plan Variant 15614PA0010004-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Low On Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 100% |
| First Tier Utilization | 100% |
| HIOS Product ID | 15614PA001 |
| Import Date | 1/23/2023 |
| Guaranteed Rate | Guaranteed Rate |
| IsItANewPlan | Existing |
| Issuer ID | 15614 |
| Market Coverage | Individual |
| 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), Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, In Network (Tier 1), Individual | Not Applicable |
| 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 | $375 per person | $750 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $375 |
| 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 | Low |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | PAN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency pain treatment only if 50 miles away from home ZIP code, up to $100 |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency pain treatment only if 50 miles away from home ZIP code, up to $100 |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 15614PA0010004-01 |
| Plan Level Exclusions | Out of Pocket Maximum applies to children only. Co-insurance equivalent percentages displayed. Discount provided for non-medically necessary orthodontia. Must choose participating Select Plan dentist. |
| Plan Marketing Name | Select Plan Basic |
| Plan Type | HMO |
| Plan Variant Marketing Name | Select Plan Basic |
| QHP/Non QHP | Both |
| Service Area ID | PAS001 |
| Source Name | SERFF |
| Plan ID | 15614PA0010004 |
| State Code | PA |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Select Plan Basic Health Insurance Plan, 15614PA0010004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Select Plan Basic, 15614PA0010004 Health Insurance Plan, 15614PA0010004
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Does Select Plan Basic Health Insurance Plan, 15614PA0010004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (15614PA0010004) Health Insurance Plan, Variant (15614PA0010004-01) have Out Of Country Coverage?
Yes. Details: Emergency pain treatment only if 50 miles away from home ZIP code, up to $100
Does (15614PA0010004) Health Insurance Plan, Variant (15614PA0010004-01) have Out of Service Area Coverage?
Yes. Details: Emergency pain treatment only if 50 miles away from home ZIP code, up to $100
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