SelectHealth Med Gold Copay Plan - 26002ID0030048 Health Insurance Plan
SelectHealth health insurance plan with the Plan ID 26002ID0030048. The plan is called SelectHealth Med Gold Copay Plan.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.62% (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 20.38% 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 | 26002ID0030048 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Idaho | ||||||||||||||||||
| Health Insurance Issuer | SelectHealth | ||||||||||||||||||
| Health Insurance Plan Variant | 26002ID0030048-01 | ||||||||||||||||||
| Provider Network(s) | ['IDN004'] | ||||||||||||||||||
| 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 |
SelectHealth Med Gold Copay Plan Health Insurance Plan Variant 26002ID0030048-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.796154218 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | Yes |
| 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 | 30.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family | $0 per person | $0 per group |
| Drug EHB Deductible, Out of Network, Individual | $0 |
| 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 | 100% |
| Formulary ID | IDF007 |
| HIOS Product ID | 26002ID003 |
| HSA/HRA Employer Contribution | No |
| Import Date | 1/23/2023 |
| Inpatient Copayment Maximum Days | 3 |
| HSA Eligible | No |
| IsItANewPlan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 26002 |
| 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 | 30.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family | $3000 per person | $9000 per group |
| Medical EHB Deductible, Out of Network, Individual | $3,000 |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | IDN004 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 26002ID0030048-01 |
| Plan Level Exclusions | Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses; computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items. |
| Plan Marketing Name | SelectHealth Med Gold Copay Plan |
| Plan Type | POS |
| Plan Variant Marketing Name | SelectHealth Med Gold Copay Plan |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,500 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,500 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $70 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,700 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | IDS004 |
| Source Name | SERFF |
| Plan ID | 26002ID0030048 |
| State Code | ID |
| 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 | $6500 per person | $13000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $20000 per person | $40000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $20,000 |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of SelectHealth Med Gold Copay Plan Health Insurance Plan, 26002ID0030048
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about SelectHealth Med Gold Copay Plan, 26002ID0030048 Health Insurance Plan, 26002ID0030048
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Does SelectHealth Med Gold Copay Plan Health Insurance Plan, 26002ID0030048 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (26002ID0030048) Health Insurance Plan, Variant (26002ID0030048-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol
Does (26002ID0030048) Health Insurance Plan, Variant (26002ID0030048-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (26002ID0030048) Health Insurance Plan, Variant (26002ID0030048-01) have Out of Service Area Coverage?
Yes. Details: Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials
Does (26002ID0030048) Health Insurance Plan, Variant (26002ID0030048-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol
Does SelectHealth Med Gold Copay Plan Health Insurance Plan, Variant (26002ID0030048-01) offer Disease Management Programs for Asthma?
Yes, the SelectHealth Med Gold Copay Plan Health Insurance Plan Variant
26002ID0030048-01 offers Disease
Management Program for Asthma.
Does SelectHealth Med Gold Copay Plan Health Insurance Plan, Variant (26002ID0030048-01) offer Disease Management Programs for Heart disease?
Yes, the SelectHealth Med Gold Copay Plan Health Insurance Plan Variant
26002ID0030048-01 offers Disease
Management Program for Heart disease.
Does SelectHealth Med Gold Copay Plan Health Insurance Plan, Variant (26002ID0030048-01) offer Disease Management Programs for Depression?
Yes, the SelectHealth Med Gold Copay Plan Health Insurance Plan Variant
26002ID0030048-01 offers Disease
Management Program for Depression.
Does SelectHealth Med Gold Copay Plan Health Insurance Plan, Variant (26002ID0030048-01) offer Disease Management Programs for Diabetes?
Yes, the SelectHealth Med Gold Copay Plan Health Insurance Plan Variant
26002ID0030048-01 offers Disease
Management Program for Diabetes.
Does SelectHealth Med Gold Copay Plan Health Insurance Plan, Variant (26002ID0030048-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the SelectHealth Med Gold Copay Plan Health Insurance Plan Variant
26002ID0030048-01 offers Disease
Management Program for High blood pressure & high cholesterol.
Does SelectHealth Med Gold Copay Plan Health Insurance Plan, Variant (26002ID0030048-01) offer Disease Management Programs for Low back pain?
Yes, the SelectHealth Med Gold Copay Plan Health Insurance Plan Variant
26002ID0030048-01 offers Disease
Management Program for Low back pain.
Does SelectHealth Med Gold Copay Plan Health Insurance Plan, Variant (26002ID0030048-01) offer Disease Management Programs for Pregnancy?
Yes, the SelectHealth Med Gold Copay Plan Health Insurance Plan Variant
26002ID0030048-01 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