SilverPlus-S1, ST, INN, Pediatric Dental, Dep29, Healthy Living Rewards, Metro-MP - 11177NY0040002 Health Insurance Plan

MetroPlus health insurance plan with the Plan ID 11177NY0040002. The plan is called SilverPlus-S1, ST, INN, Pediatric Dental, Dep29, Healthy Living Rewards, Metro-MP.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 72.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.00% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 72.00% (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 28.00% 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 11177NY0040002
Health Insurance Plan Year 2024
State New York
Health Insurance Issuer MetroPlus
Health Insurance Plan Variant 11177NY0040002-03
Provider Network(s) ['NYN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers New York All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard On Exchange Plan - 11177NY0040002-01

Open to Indians below 300% FPL - 11177NY0040002-02

Open to Indians above 300% FPL - 11177NY0040002-03

73% AV Silver Plan - 11177NY0040002-04

87% AV Silver Plan - 11177NY0040002-05

94% AV Silver Plan - 11177NY0040002-06

Last Plan Update Date Mon, 12 Feb 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

SilverPlus-S1, ST, INN, Pediatric Dental, Dep29, Healthy Living Rewards, Metro-MP Health Insurance Plan Variant 11177NY0040002-03 Attributes

Plan Attribute Value
AV Calculator Output Number 0.719970954
Begin Primary Care Deductible Coinsurance After Number Of Copays 1
Business Year 2024
Child-Only Offering Allows Adult-Only
Child Only Plan ID 11177NY0030002
Composite Rating Offered No
CSR Variation Type Limited Cost Sharing Plan Variation
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 $0 per person | $0 per group
Drug EHB Deductible, In Network (Tier 1), Individual $0
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 99%
First Tier Utilization 100%
Formulary ID NYF002
HIOS Product ID 11177NY004
Import Date 2/12/2024
HSA Eligible No
IsItANewPlan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? Yes
Issuer Actuarial Value 72.00%
Issuer ID 11177
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 30.00%
Medical EHB Deductible, In Network (Tier 1), Family $2100 per person | $4200 per group
Medical EHB Deductible, In Network (Tier 1), Individual $2,100
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 NYN001
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Only
Plan Effective Date 1/1/2024
Plan Expiration Date 12/31/2024
Plan ID (Standard Component ID with Variant) 11177NY0040002-03
Plan Marketing Name SilverPlus-S1, ST, INN, Pediatric Dental, Dep29, Healthy Living Rewards, Metro-MP
Plan Type HMO
Plan Variant Marketing Name SilverPlus-S1, ST, INN, Pediatric Dental, Dep29, Healthy Living Rewards, Metro-MP
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $2,200
SBC Scenario, Having a Baby, Deductible $2,100
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $200
SBC Scenario, Having Diabetes, Copayment $500
SBC Scenario, Having Diabetes, Deductible $2,100
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $11
SBC Scenario, Treatment of a Simple Fracture, Copayment $400
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,100
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID NYS001
Source Name SERFF
Specialist Requiring a Referral All specialists with the exception of assigned Primary and preventive obstetric and gynecologic provider
Plan ID 11177NY0040002
State Code NY
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 $9450 per person | $18900 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,450
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 SilverPlus-S1, ST, INN, Pediatric Dental, Dep29, Healthy Living Rewards, Metro-MP Health Insurance Plan, 11177NY0040002

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about SilverPlus-S1, ST, INN, Pediatric Dental, Dep29, Healthy Living Rewards, Metro-MP, 11177NY0040002 Health Insurance Plan, 11177NY0040002

  • Does SilverPlus-S1, ST, INN, Pediatric Dental, Dep29, Healthy Living Rewards, Metro-MP Health Insurance Plan, 11177NY0040002 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (11177NY0040002) Health Insurance Plan, Variant (11177NY0040002-03) have Out Of Country Coverage?

    Yes. Details: Emergency Only

    Does (11177NY0040002) Health Insurance Plan, Variant (11177NY0040002-03) have Out of Service Area Coverage?

    Yes. Details: Emergency Only

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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