Avera 3500 - 60536SD0020022 Health Insurance Plan

Avera Health Plans, Inc. health insurance plan with the Plan ID 60536SD0020022. The plan is called Avera 3500.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.69% (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 28.31% 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 60536SD0020022
Health Insurance Plan Year 2023
State South Dakota
Health Insurance Issuer Avera Health Plans, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 60536SD0020022-00
Provider Network(s) ['SDN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers South Dakota 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 - 60536SD0020022-00

Standard On Exchange Plan - 60536SD0020022-01

Open to Indians below 300% FPL - 60536SD0020022-02

Open to Indians above 300% FPL - 60536SD0020022-03

73% AV Silver Plan - 60536SD0020022-04

87% AV Silver Plan - 60536SD0020022-05

94% AV Silver Plan - 60536SD0020022-06

Last Plan Update Date Wed, 17 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Avera 3500 Health Insurance Plan, 60536SD0020022-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Bariatric Surgery

Limit: 1.0 Procedure(s) per Lifetime

YES

40.00% Coinsurance after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child

Limit: 1.0 Visit(s) per 6 Months

YES

No Charge

100.00%
Chemotherapy
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chiropractic Care

Preauthorization required after 20 visits per plan year. No coverage for services without preauthorization.

YES

$50.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

YES

No Charge

100.00%
Diabetes Education

Limit: 8.0 Visit(s) per Year

State law allows two education programs per lifetime and up to 8 follow-up visits per year

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dialysis
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Durable Medical Equipment

Exclusions: Certain durable medical equipment require preauthorization. No coverage for services without preauthorization.

YES

40.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Exclusions: Preauthorization for non-emergency transportation. No coverage for services without preauthorization.

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

$12.00

100.00%
Habilitation Services

Treatment for Autism Spectrum Disorder (ASD) with speech therapy, occupational therapy, or physical therapy is covered. Use of Applied Behavioral Analysis (ABA) for the treatment of ASD is covered with the following minimum coverage limits: 1) through age 6: 1300 hours per benefit period; 2) ages 7-13: 900 hours per benefit period; 3) ages 14-18: 450 hours per benefit period. Preauthorization required after 30 visits per plan year for each therapy: physical, occupational and speech.

YES

$50.00

50.00% Coinsurance after deductible
Hearing Aids
NO
Home Health Care Services

Exclusions: 60-visit limit per plan year for services from non-participating providers. One visit equals a maximum of 4 hours, including private duty nursing.

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Hospice Services

Limit: 185.0 Days per Year

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)

Exclusions: Some imaging requires preauthorization.

Major lab and X-ray services may include PET scan, MRI, CT scan, SPECT scan, cardiovascular, nuclear medicine and MRA.

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infertility Treatment
NO
Infusion Therapy
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)

Exclusions: Preauthorization required. No coverage for services without preauthorization

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services

Exclusions: Preauthorization required. No coverage for services without preauthorization

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child

Frequency limitations may apply

YES

50.00%

100.00%
Mental/Behavioral Health Inpatient Services

Exclusions: Preauthorization for non-emergency transportation. No coverage for services without preauthorization.

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services

Coinsurance will apply for services other than therapy performed in the office or any service at a facility.

YES

$50.00

50.00% Coinsurance after deductible
Non-Preferred Brand Drugs
YES

$125.00

100.00%
Nutritional Counseling
NO
Orthodontia - Adult
NO
Orthodontia - Child

Frequency limitations may apply

YES

50.00%

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$50.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Outpatient Rehabilitation Services

Preauthorization required after 30 visits per plan year for each therapy: physical, occupational and speech.

YES

$50.00

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preferred Brand Drugs
YES

$40.00

100.00%
Prenatal and Postnatal Care

Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization

Age and frequency limitations may apply

YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$50.00

50.00% Coinsurance after deductible
Private-Duty Nursing
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Prosthetic Devices
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Radiation
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Reconstructive Surgery
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Preauthorization required after 30 visits per plan year.

YES

$50.00

50.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Preauthorization required after 30 visits per plan year.

YES

$50.00

50.00% Coinsurance after deductible
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 100.0 Days per Admission

100-day confinement limit is for services from participating providers. 60-day confinement limit for services from non-participating providers. Same confinement limit if readmitted with same diagnosis within 60 days.

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Specialist Visit
YES

$100.00

50.00% Coinsurance after deductible
Specialty Drugs
YES

30.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services

Coinsurance will apply for services other than therapy performed in the office or any service at a facility.

YES

$50.00

50.00% Coinsurance after deductible
Transplant
YES

40.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Urgent Care Centers or Facilities

In-network benefit for services outside of service area. When using Out-of-Network Provider inside service area you may contact the plan to determine if your visit qualifies for in-network benefits.

YES

$50.00

50.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care

Age and frequency limitations may apply

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible

Avera 3500 Health Insurance Plan Variant 60536SD0020022-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.716932084
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
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
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID SDF002
Formulary URL URL
HIOS Product ID 60536SD002
Import Date 8/17/2022 20:01
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 60536
Issuer Marketplace Marketing Name Avera Health Plans
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 40.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $7000 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $3500 per person
Medical EHB Deductible, In Network (Tier 1), Individual $3,500
Medical EHB Deductible, Out of Network, Family Per Group $20000 per group
Medical EHB Deductible, Out of Network, Family Per Person $10000 per person
Medical EHB Deductible, Out of Network, Individual $10,000
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID SDN001
Out of Country Coverage No
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency or urgent care services are covered if traveling outside of our service area. No coverage for health services if you travel outside our service area for the purpose of seeking medical treatment.
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 60536SD0020022-00
Plan Level Exclusions Abortion (except when the life of the mother is endangered), acupuncture, cosmetic surgery, dental care for adults, hearing aids, infertility treatment, long-term care, non-emergency care when traveling outside the United States, routine eye care for adults, and weight loss programs.
Plan Marketing Name Avera 3500
Plan Type PPO
Plan Variant Marketing Name Avera 3500
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,600
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $3,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,100
SBC Scenario, Having Diabetes, Deductible $900
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 SDS001
Source Name SERFF
Plan ID 60536SD0020022
State Code SD
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 $18000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,000
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 Avera 3500 Health Insurance Plan, 60536SD0020022

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

Frequently Asked Questions(FAQ) about Avera 3500, 60536SD0020022 Health Insurance Plan, 60536SD0020022

  • Does Avera 3500 Health Insurance Plan, 60536SD0020022 support Mail Ordering?

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

  • Does (60536SD0020022) Health Insurance Plan, Variant (60536SD0020022-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does (60536SD0020022) Health Insurance Plan, Variant (60536SD0020022-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (60536SD0020022) Health Insurance Plan, Variant (60536SD0020022-00) have Out of Service Area Coverage?

    Yes. Details: Emergency or urgent care services are covered if traveling outside of our service area. No coverage for health services if you travel outside our service area for the purpose of seeking medical treatment.

    Does (60536SD0020022) Health Insurance Plan, Variant (60536SD0020022-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does Avera 3500 Health Insurance Plan, Variant (60536SD0020022-00) offer Disease Management Programs for Asthma?

    Yes, the Avera 3500 Health Insurance Plan Variant 60536SD0020022-00 offers Disease Management Program for Asthma.

    Does Avera 3500 Health Insurance Plan, Variant (60536SD0020022-00) offer Disease Management Programs for Heart disease?

    Yes, the Avera 3500 Health Insurance Plan Variant 60536SD0020022-00 offers Disease Management Program for Heart disease.

    Does Avera 3500 Health Insurance Plan, Variant (60536SD0020022-00) offer Disease Management Programs for Diabetes?

    Yes, the Avera 3500 Health Insurance Plan Variant 60536SD0020022-00 offers Disease Management Program for Diabetes.

    Does Avera 3500 Health Insurance Plan, Variant (60536SD0020022-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Avera 3500 Health Insurance Plan Variant 60536SD0020022-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Avera 3500 Health Insurance Plan, Variant (60536SD0020022-00) offer Disease Management Programs for Pregnancy?

    Yes, the Avera 3500 Health Insurance Plan Variant 60536SD0020022-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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