Standard Low Silver HSA: Tufts Health Direct Silver 2000 HSA - 59763MA0030020 Health Insurance Plan
Tufts Health Public Plans health insurance plan with the Plan ID 59763MA0030020. The plan is called Standard Low Silver HSA: Tufts Health Direct Silver 2000 HSA.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.62% (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 29.38% 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 | 59763MA0030020 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Massachusetts | ||||||||||||||||||
| Health Insurance Issuer | Tufts Health Public Plans | ||||||||||||||||||
| Health Insurance Plan Variant | 59763MA0030020-01 | ||||||||||||||||||
| Provider Network(s) | ['MAN002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 May 2024 06:08 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Mon, 22 May 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Standard Low Silver HSA: Tufts Health Direct Silver 2000 HSA Health Insurance Plan Variant 59763MA0030020-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.706199774 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver On Exchange Plan |
| Dental Only Plan | No |
| First Tier Utilization | 100% |
| Formulary ID | MAF007 |
| HIOS Product ID | 59763MA003 |
| HSA/HRA Employer Contribution | No |
| Import Date | 5/22/2023 |
| HSA Eligible | Yes |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 59763 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MAN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Care Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Care Only |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 59763MA0030020-01 |
| Plan Marketing Name | Standard Low Silver HSA: Tufts Health Direct Silver 2000 HSA |
| Plan Type | HMO |
| Plan Variant Marketing Name | Standard Low Silver HSA: Tufts Health Direct Silver 2000 HSA |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $800 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,300 |
| SBC Scenario, Having Diabetes, Deductible | $2,000 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MAS002 |
| Source Name | SERFF |
| Plan ID | 59763MA0030020 |
| State Code | MA |
| 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 | $2000 per person | $4000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| TEHBDedOutofNetFamily | per person not applicable | per group 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 | $7050 per person | $14100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,050 |
| 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 | No |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Standard Low Silver HSA: Tufts Health Direct Silver 2000 HSA Health Insurance Plan, 59763MA0030020
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Standard Low Silver HSA: Tufts Health Direct Silver 2000 HSA, 59763MA0030020 Health Insurance Plan, 59763MA0030020
-
Does Standard Low Silver HSA: Tufts Health Direct Silver 2000 HSA Health Insurance Plan, 59763MA0030020 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (59763MA0030020) Health Insurance Plan, Variant (59763MA0030020-01) have Out Of Country Coverage?
Yes. Details: Emergency Care Only
Does (59763MA0030020) Health Insurance Plan, Variant (59763MA0030020-01) have Out of Service Area Coverage?
Yes. Details: Emergency Care Only
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