Signature Benchmark Gold Standardized Plan - 68781UT0200022 Health Insurance Plan
SelectHealth, Inc. health insurance plan with the Plan ID 68781UT0200022. The plan is called Signature Benchmark Gold Standardized Plan .
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.00% (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 22.00% 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 | 68781UT0200022 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | SelectHealth, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 68781UT0200022-00 | ||||||||||||||||||
| Provider Network(s) | ['UTN003'] | ||||||||||||||||||
| 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 - 68781UT0200022-00 Standard On Exchange Plan - 68781UT0200022-01 |
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| Last Plan Update Date | Thu, 25 May 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Benefits of Signature Benchmark Gold Standardized Plan Health Insurance Plan, 68781UT0200022-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | 100.00% |
100.00% |
| Accidental Dental
|
NO | 100.00% |
100.00% |
| Acupuncture
|
NO | 100.00% |
100.00% |
| Allergy Testing
|
YES | $60.00 |
100.00% |
| Autism Spectrum Disorders
Covered as required by state law. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | 100.00% |
100.00% |
| Basic Dental Care - Adult
|
NO | 100.00% |
100.00% |
| Basic Dental Care - Child
|
NO | 100.00% |
100.00% |
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
|
NO | 100.00% |
100.00% |
| Cosmetic Surgery
|
NO | 100.00% |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
Member responsibility is on a per-day basis up to 3 days. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | 100.00% |
100.00% |
| Diabetes Education
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Exclusions: Certain limitations and exclusions exist. Refer to the plan materials for more information. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: Frames are not covered |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Certain generic and brand name drugs have lower cost sharing than the generic tier |
YES | $15.00 |
$15.00 |
| Habilitation Services
Limit: 20.0 Visit(s) per Year Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. |
YES | $30.00 |
100.00% |
| Hearing Aids
|
NO | 100.00% |
100.00% |
| Home Health Care Services
Limit: 30.0 Visit(s) per Year |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Limit: 6.0 Months per 3 Years |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | 100.00% |
100.00% |
| Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inherited Metabolic Disorder - PKU
|
YES | $60.00 |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Member responsibility is on a per-day basis up to 3 days. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | 100.00% |
100.00% |
| Major Dental Care - Adult
|
NO | 100.00% |
100.00% |
| Major Dental Care - Child
|
NO | 100.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
Exclusions: Certain limitations and exclusions exist. Refer to the plan materials for more information. Member responsibility is on a per-day basis up to 3 days. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: Certain limitations and exclusions exist. Refer to the plan materials for more information. Office visits for Mental/Behavioral Health Outpatient Services: please refer to the Primary Care Visit for cost sharing information |
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $60.00 |
$60.00 |
| Nutritional Counseling
|
NO | 100.00% |
100.00% |
| Orthodontia - Adult
|
NO | 100.00% |
100.00% |
| Orthodontia - Child
|
NO | 100.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
A procedure in a Freestanding Ambulatory Surgery Center, will cost the member less than the amount shown for other outpatient facilities. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have a combined limit of 30 days. |
YES | $30.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $30.00 |
$30.00 |
| Prenatal and Postnatal Care
|
YES | $30.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
| Private-Duty Nursing
|
NO | 100.00% |
100.00% |
| Prosthetic Devices
|
NO | 100.00% |
100.00% |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: Covered only in limited circumstances Member responsibility is on a per-day basis up to 3 days. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Days per Year Member responsibility is on a per-day basis up to 3 days. Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have a combined limit of 40 days. |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Days per Year Member responsibility is on a per-day basis up to 3 days. Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have a combined limit of 40 days. |
YES | $30.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | 100.00% |
100.00% |
| Routine Eye Exam (Adult)
|
NO | 100.00% |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | 100.00% |
100.00% |
| Skilled Nursing Facility
Limit: 30.0 Days per Year Member responsibility is on a per-day basis up to 3 days. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
|
YES | $250.00 |
$250.00 |
| Substance Abuse Disorder Inpatient Services
Exclusions: Certain limitations and exclusions exist. Refer to the plan materials for more information. Member responsibility is on a per-day basis up to 3 days. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: Certain limitations and exclusions exist. Refer to the plan materials for more information. Office visits for Mental/Behavioral Health Outpatient Services: please refer to the Primary Care Visit for cost sharing information |
YES | $30.00 |
100.00% |
| Transplant
Exclusions: Covered only in limited circumstances Member responsibility is on a per-day basis up to 3 days. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | 100.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $45.00 |
100.00% |
| Weight Loss Programs
|
NO | 100.00% |
100.00% |
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Signature Benchmark Gold Standardized Plan Health Insurance Plan Variant 68781UT0200022-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.780017779 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | UTF011 |
| Formulary URL | URL |
| HIOS Product ID | 68781UT020 |
| Import Date | 5/25/2023 20:02 |
| 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 | 68781 |
| Issuer Marketplace Marketing Name | SelectHealth |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | UTN003 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Urgent or emergency care only |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Urgent or emergency care only |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 68781UT0200022-00 |
| 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; 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 | Signature Benchmark Gold Standardized Plan |
| Plan Type | HMO |
| Plan Variant Marketing Name | Signature Benchmark Gold Standardized Plan |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,600 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | UTS004 |
| Source Name | SERFF |
| Plan ID | 68781UT0200022 |
| State Code | UT |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $4000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| 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 | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Signature Benchmark Gold Standardized Plan Health Insurance Plan, 68781UT0200022
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Signature Benchmark Gold Standardized Plan , 68781UT0200022 Health Insurance Plan, 68781UT0200022
-
Does Signature Benchmark Gold Standardized Plan Health Insurance Plan, 68781UT0200022 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (68781UT0200022) Health Insurance Plan, Variant (68781UT0200022-00) offer Disease Management Programs?
Does (68781UT0200022) Health Insurance Plan, Variant (68781UT0200022-00) have Out Of Country Coverage?
Does (68781UT0200022) Health Insurance Plan, Variant (68781UT0200022-00) have Out of Service Area Coverage?
Does (68781UT0200022) Health Insurance Plan, Variant (68781UT0200022-00) offer Disease Management Programs?
Does Signature Benchmark Gold Standardized Plan Health Insurance Plan, Variant (68781UT0200022-00) offer Disease Management Programs for Asthma?
Does Signature Benchmark Gold Standardized Plan Health Insurance Plan, Variant (68781UT0200022-00) offer Disease Management Programs for Heart disease?
Does Signature Benchmark Gold Standardized Plan Health Insurance Plan, Variant (68781UT0200022-00) offer Disease Management Programs for Depression?
Does Signature Benchmark Gold Standardized Plan Health Insurance Plan, Variant (68781UT0200022-00) offer Disease Management Programs for Diabetes?
Does Signature Benchmark Gold Standardized Plan Health Insurance Plan, Variant (68781UT0200022-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Signature Benchmark Gold Standardized Plan Health Insurance Plan, Variant (68781UT0200022-00) offer Disease Management Programs for Low back pain?
Does Signature Benchmark Gold Standardized Plan Health Insurance Plan, Variant (68781UT0200022-00) offer Disease Management Programs for Pregnancy?
Does Signature Benchmark Gold Standardized Plan Health Insurance Plan, Variant (68781UT0200022-00) offer Disease Management Programs for Weight loss programs?
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