St Luke's Health Plan Gold - 92170ID0170004 Health Insurance Plan
St. Luke's Health Plan health insurance plan with the Plan ID 92170ID0170004. The plan is called St Luke's Health Plan Gold.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.50% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.50% 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 81.87% (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 18.13% 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 | 92170ID0170004 | ||||||||||||||||||
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| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Idaho | ||||||||||||||||||
| Health Insurance Issuer | St. Luke's Health Plan | ||||||||||||||||||
| Health Insurance Plan Variant | 92170ID0170004-01 | ||||||||||||||||||
| Provider Network(s) | ['IDN001'] | ||||||||||||||||||
| 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 - 92170ID0170004-01 |
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| Last Plan Update Date | Mon, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
St Luke's Health Plan Gold Health Insurance Plan Variant 92170ID0170004-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.818709739 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 100% |
| First Tier Utilization | 100% |
| Formulary ID | IDF004 |
| HIOS Product ID | 92170ID017 |
| Import Date | 1/23/2023 |
| HSA Eligible | No |
| IsItANewPlan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 81.50% |
| Issuer ID | 92170 |
| 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 | IDN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 92170ID0170004-01 |
| Plan Marketing Name | St Luke's Health Plan Gold |
| Plan Type | POS |
| Plan Variant Marketing Name | St Luke's Health Plan Gold |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $800 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $1,800 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $800 |
| SBC Scenario, Having Diabetes, Copayment | $70 |
| SBC Scenario, Having Diabetes, Deductible | $1,800 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | IDS001 |
| Source Name | SERFF |
| Plan ID | 92170ID0170004 |
| 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 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $1800 per person | $3600 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,800 |
| TEHBDedOutofNetFamily | $18200 per person | $36400 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $18,200 |
| 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 | $91000 per person | $182000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $91,000 |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of St Luke's Health Plan Gold Health Insurance Plan, 92170ID0170004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about St Luke's Health Plan Gold, 92170ID0170004 Health Insurance Plan, 92170ID0170004
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Does St Luke's Health Plan Gold Health Insurance Plan, 92170ID0170004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (92170ID0170004) Health Insurance Plan, Variant (92170ID0170004-01) have Out Of Country Coverage?
Does (92170ID0170004) Health Insurance Plan, Variant (92170ID0170004-01) have Out of Service Area Coverage?
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