Value Gold 1500 - no deductible for office visits - 68781UT0020023 Health Insurance Plan
SelectHealth, Inc. health insurance plan with the Plan ID 68781UT0020023. The plan is called Value Gold 1500 - no deductible for office visits.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.65% (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 18.35% 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 | 68781UT0020023 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | SelectHealth, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 68781UT0020023-00 | ||||||||||||||||||
| Provider Network(s) | ['UTN002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 68781UT0020023-00 Standard On Exchange Plan - 68781UT0020023-01 |
||||||||||||||||||
| Last Plan Update Date | Wed, 18 Aug 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Value Gold 1500 - no deductible for office visits Health Insurance Plan Variant 68781UT0020023-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.816465252 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2022 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $250 per person |
| Drug EHB Deductible, Combined In/Out of Network, Individual | $250 |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | per group not applicable |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | per person not applicable |
| Drug EHB Deductible, In Network (Tier 1), Individual | Not Applicable |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| 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 | 0.9907 |
| First Tier Utilization | 100% |
| Formulary ID | UTF011 |
| Formulary URL | URL |
| HIOS Product ID | 68781UT002 |
| Import Date | 8/18/2021 20:00 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| 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 | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person 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 Per Group | $3000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | UTN002 |
| 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 | 1/1/2022 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 68781UT0020023-00 |
| 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 | Value Gold 1500 - no deductible for office visits |
| Plan Type | HMO |
| Plan Variant Marketing Name | Value Gold 1500 - no deductible for office visits |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,300 |
| SBC Scenario, Having a Baby, Copayment | $100 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $900 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | UTS002 |
| Source Name | SERFF |
| Plan ID | 68781UT0020023 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $12000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,000 |
| 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 Value Gold 1500 - no deductible for office visits Health Insurance Plan, 68781UT0020023
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Value Gold 1500 - no deductible for office visits, 68781UT0020023 Health Insurance Plan, 68781UT0020023
-
Does Value Gold 1500 - no deductible for office visits Health Insurance Plan, 68781UT0020023 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (68781UT0020023) Health Insurance Plan, Variant (68781UT0020023-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does (68781UT0020023) Health Insurance Plan, Variant (68781UT0020023-00) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan). Details: Urgent or emergency care only
Does (68781UT0020023) Health Insurance Plan, Variant (68781UT0020023-00) have Out of Service Area Coverage?
No, unfortunately there
is no Out of Service Area Coverage for this Health Insurance
Plan (variant of plan). Details: Urgent or emergency care only
Does (68781UT0020023) Health Insurance Plan, Variant (68781UT0020023-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does Value Gold 1500 - no deductible for office visits Health Insurance Plan, Variant (68781UT0020023-00) offer Disease Management Programs for Asthma?
Yes, the Value Gold 1500 - no deductible for office visits Health Insurance Plan Variant
68781UT0020023-00 offers Disease
Management Program for Asthma.
Does Value Gold 1500 - no deductible for office visits Health Insurance Plan, Variant (68781UT0020023-00) offer Disease Management Programs for Heart disease?
Yes, the Value Gold 1500 - no deductible for office visits Health Insurance Plan Variant
68781UT0020023-00 offers Disease
Management Program for Heart disease.
Does Value Gold 1500 - no deductible for office visits Health Insurance Plan, Variant (68781UT0020023-00) offer Disease Management Programs for Depression?
Yes, the Value Gold 1500 - no deductible for office visits Health Insurance Plan Variant
68781UT0020023-00 offers Disease
Management Program for Depression.
Does Value Gold 1500 - no deductible for office visits Health Insurance Plan, Variant (68781UT0020023-00) offer Disease Management Programs for Diabetes?
Yes, the Value Gold 1500 - no deductible for office visits Health Insurance Plan Variant
68781UT0020023-00 offers Disease
Management Program for Diabetes.
Does Value Gold 1500 - no deductible for office visits Health Insurance Plan, Variant (68781UT0020023-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Value Gold 1500 - no deductible for office visits Health Insurance Plan Variant
68781UT0020023-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Value Gold 1500 - no deductible for office visits Health Insurance Plan, Variant (68781UT0020023-00) offer Disease Management Programs for Low back pain?
Yes, the Value Gold 1500 - no deductible for office visits Health Insurance Plan Variant
68781UT0020023-00 offers Disease
Management Program for Low back pain.
Does Value Gold 1500 - no deductible for office visits Health Insurance Plan, Variant (68781UT0020023-00) offer Disease Management Programs for Pregnancy?
Yes, the Value Gold 1500 - no deductible for office visits Health Insurance Plan Variant
68781UT0020023-00 offers Disease
Management Program for Pregnancy.
Does Value Gold 1500 - no deductible for office visits Health Insurance Plan, Variant (68781UT0020023-00) offer Disease Management Programs for Weight loss programs?
Yes, the Value Gold 1500 - no deductible for office visits Health Insurance Plan Variant
68781UT0020023-00 offers Disease
Management Program 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