Silver 70 Ambetter HMO - 67138CA0520016 Health Insurance Plan
Health Net of California health insurance plan with the Plan ID 67138CA0520016. The plan is called Silver 70 Ambetter HMO.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.68% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.32% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 67138CA0520016 | ||||||||||||||||||
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| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | California | ||||||||||||||||||
| Health Insurance Issuer | Health Net of California | ||||||||||||||||||
| Health Insurance Plan Variant | 67138CA0520016-01 | ||||||||||||||||||
| Provider Network(s) | ['CAN001'] | ||||||||||||||||||
| 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 | Standard On Exchange Plan - 67138CA0520016-01 Open to Indians below 300% FPL - 67138CA0520016-02 Open to Indians above 300% FPL - 67138CA0520016-03 73% AV Silver Plan - 67138CA0520016-04 |
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| Last Plan Update Date | Mon, 17 Apr 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Silver 70 Ambetter HMO Health Insurance Plan Variant 67138CA0520016-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver 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 | 20.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $85 per person | $170 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $85 |
| 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 |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 100% |
| First Tier Utilization | 100% |
| Formulary ID | CAF003 |
| HIOS Product ID | 67138CA052 |
| Import Date | 4/17/2023 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 71.68% |
| Issuer ID | 67138 |
| Market Coverage | Individual |
| 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 | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $4750 per person | $9500 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $4,750 |
| 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 | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | CAN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 67138CA0520016-01 |
| Plan Marketing Name | Silver 70 Ambetter HMO |
| Plan Type | HMO |
| Plan Variant Marketing Name | Silver 70 Ambetter HMO |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $1,100 |
| SBC Scenario, Having a Baby, Copayment | $800 |
| SBC Scenario, Having a Baby, Deductible | $4,800 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $200 |
| SBC Scenario, Having Diabetes, Copayment | $1,600 |
| SBC Scenario, Having Diabetes, Deductible | $85 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $50 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $50 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | CAS009 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All specialists require referral by PCP except Obstetrics and Gynecology |
| Specialty Drug Maximum Coinsurance | $250 |
| Plan ID | 67138CA0520016 |
| State Code | CA |
| 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 | $8750 per person | $17500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,750 |
| 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 | Yes |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Silver 70 Ambetter HMO Health Insurance Plan, 67138CA0520016
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Silver 70 Ambetter HMO, 67138CA0520016 Health Insurance Plan, 67138CA0520016
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Does Silver 70 Ambetter HMO Health Insurance Plan, 67138CA0520016 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (67138CA0520016) Health Insurance Plan, Variant (67138CA0520016-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (67138CA0520016) Health Insurance Plan, Variant (67138CA0520016-01) have Out of Service Area Coverage?
No, unfortunately there
is no Out of Service Area Coverage for this Health Insurance
Plan (variant of plan).
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