WellFirst Silver Value Copay 5000X - 65280IL0010006 Health Insurance Plan

SSM Health Plan health insurance plan with the Plan ID 65280IL0010006. The plan is called WellFirst Silver Value Copay 5000X.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 67.67% (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 32.33% 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 65280IL0010006
Health Insurance Plan Year 2022
State Illinois
Health Insurance Issuer SSM Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 65280IL0010006-00
Provider Network(s) ['ILN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Jul 2024 06:14 GMT).

Providers Illinois 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 Off Exchange Plan - 65280IL0010006-00

Standard On Exchange Plan - 65280IL0010006-01

Open to Indians below 300% FPL - 65280IL0010006-02

Open to Indians above 300% FPL - 65280IL0010006-03

73% AV Silver Plan - 65280IL0010006-04

87% AV Silver Plan - 65280IL0010006-05

94% AV Silver Plan - 65280IL0010006-06

Last Plan Update Date Wed, 18 Aug 2021 00:00 GMT
Last Import Date Tue, 16 Jul 2024 06:14 GMT

WellFirst Silver Value Copay 5000X Health Insurance Plan Variant 65280IL0010006-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.67666398
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 3
Business Year 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Silver 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 per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Drug EHB Deductible, In Network (Tier 1), Individual $0
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, Diabetes, Pregnancy
EHB Percent of Total Premium 0.9994
First Tier Utilization 100%
Formulary ID ILF003
Formulary URL URL
HIOS Product ID 65280IL001
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 New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? Yes
Issuer ID 65280
Issuer Marketplace Marketing Name WellFirst Health
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 30.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $10000 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $5000 per person
Medical EHB Deductible, In Network (Tier 1), Individual $5,000
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 Silver
Multiple In Network Tiers No
National Network No
Network ID ILN001
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 Brochure URL
Plan Effective Date 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 65280IL0010006-00
Plan Level Exclusions See policy or plan document for additional excluded services.
Plan Marketing Name WellFirst Silver Value Copay 5000X
Plan Type HMO
Plan Variant Marketing Name WellFirst Silver Value Copay 5000X
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,200
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $5,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $1,600
SBC Scenario, Having Diabetes, Copayment $200
SBC Scenario, Having Diabetes, Deductible $1,300
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $400
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,200
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID ILS001
Source Name SERFF
Specialist Requiring a Referral All specialty services with the exception of behavioral health and addiction/substance abuse services
Plan ID 65280IL0010006
State Code IL
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 $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
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 WellFirst Silver Value Copay 5000X Health Insurance Plan, 65280IL0010006

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

Frequently Asked Questions(FAQ) about WellFirst Silver Value Copay 5000X, 65280IL0010006 Health Insurance Plan, 65280IL0010006

  • Does WellFirst Silver Value Copay 5000X Health Insurance Plan, 65280IL0010006 support Mail Ordering?

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

  • Does (65280IL0010006) Health Insurance Plan, Variant (65280IL0010006-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does (65280IL0010006) Health Insurance Plan, Variant (65280IL0010006-00) have Out Of Country Coverage?

    Yes. Details: Emergency Only

    Does (65280IL0010006) Health Insurance Plan, Variant (65280IL0010006-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Only

    Does (65280IL0010006) Health Insurance Plan, Variant (65280IL0010006-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does WellFirst Silver Value Copay 5000X Health Insurance Plan, Variant (65280IL0010006-00) offer Disease Management Programs for Asthma?

    Yes, the WellFirst Silver Value Copay 5000X Health Insurance Plan Variant 65280IL0010006-00 offers Disease Management Program for Asthma.

    Does WellFirst Silver Value Copay 5000X Health Insurance Plan, Variant (65280IL0010006-00) offer Disease Management Programs for Heart disease?

    Yes, the WellFirst Silver Value Copay 5000X Health Insurance Plan Variant 65280IL0010006-00 offers Disease Management Program for Heart disease.

    Does WellFirst Silver Value Copay 5000X Health Insurance Plan, Variant (65280IL0010006-00) offer Disease Management Programs for Diabetes?

    Yes, the WellFirst Silver Value Copay 5000X Health Insurance Plan Variant 65280IL0010006-00 offers Disease Management Program for Diabetes.

    Does WellFirst Silver Value Copay 5000X Health Insurance Plan, Variant (65280IL0010006-00) offer Disease Management Programs for Pregnancy?

    Yes, the WellFirst Silver Value Copay 5000X Health Insurance Plan Variant 65280IL0010006-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 16 Jul 2024 06:14 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