Avera Direct Standard 5800 - 60536SD0060018 Health Insurance Plan

Avera Health Plans, Inc. health insurance plan with the Plan ID 60536SD0060018. The plan is called Avera Direct Standard 5800.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.06% (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 29.94% 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 60536SD0060018
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 60536SD0060018-00
Provider Network(s) ['SDN002']
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 - 60536SD0060018-00

Standard On Exchange Plan - 60536SD0060018-01

Open to Indians below 300% FPL - 60536SD0060018-02

Open to Indians above 300% FPL - 60536SD0060018-03

73% AV Silver Plan - 60536SD0060018-04

87% AV Silver Plan - 60536SD0060018-05

94% AV Silver Plan - 60536SD0060018-06

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

Benefits of Avera Direct Standard 5800 Health Insurance Plan, 60536SD0060018-00

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

40.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

40.00% Coinsurance after deductible

100.00%
Bariatric Surgery

Limit: 1.0 Procedure(s) per Lifetime

Exclusions: Preauthorization required. No coverage for services without preauthorization

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

100.00%
Chiropractic Care

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

YES

$40.00

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

100.00%
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

100.00%
Dialysis
YES

40.00% Coinsurance after deductible

100.00%
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

Exclusions: Certain drugs require preauthorization.

The preauthorization for the drug must be approved before the drug will be covered.

YES

$20.00

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

$40.00

100.00%
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

100.00%
Hospice Services

Limit: 185.0 Days per Year

YES

40.00% Coinsurance after deductible

100.00%
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

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

40.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

Exclusions: Preauthorization required. No coverage for services without preauthorization

YES

40.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services

Exclusions: Preauthorization required. No coverage for services without preauthorization

YES

40.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

40.00% Coinsurance after deductible

100.00%
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

100.00%
Mental/Behavioral Health Outpatient Services

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

YES

$40.00

100.00%
Non-Preferred Brand Drugs

Exclusions: Certain drugs require preauthorization.

The preauthorization for the drug must be approved before the drug will be covered.

YES

$80.00 Copay after deductible

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

$40.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

40.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

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

YES

$40.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Exclusions: Certain drugs require preauthorization.

The preauthorization for the drug must be approved before the drug will be covered.

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

100.00%
Preventive Care/Screening/Immunization

Age and frequency limitations may apply

YES

0.00%

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

$40.00

100.00%
Private-Duty Nursing
YES

40.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

40.00% Coinsurance after deductible

100.00%
Radiation
YES

40.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

40.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Preauthorization required after 30 visits per plan year. No coverage for services without preauthorization. Cardiac and pulmonary rehab services from participating providers are no charge after deductible and have a 36-visit maximum per plan year. Preauthorization required for all Applied Behavioral Analysis services.

YES

$40.00

100.00%
Rehabilitative Speech Therapy

Preauthorization required after 30 visits per plan year. No coverage for services without preauthorization. Cardiac and pulmonary rehab services from participating providers are no charge after deductible and have a 36-visit maximum per plan year. Preauthorization required for all Applied Behavioral Analysis services.

YES

$40.00

100.00%
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

100.00%
Specialist Visit
YES

$80.00

100.00%
Specialty Drugs

Exclusions: Certain drugs require preauthorization.

The preauthorization for the drug must be approved before the drug will be covered.

YES

$350.00 Copay after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

40.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

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

YES

$40.00

100.00%
Transplant
YES

40.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

40.00% Coinsurance after deductible

100.00%
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

$60.00

100.00%
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

100.00%

Avera Direct Standard 5800 Health Insurance Plan Variant 60536SD0060018-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.700578499
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
Dental Only Plan No
Design Type Design 1
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 SDF006
Formulary URL URL
HIOS Product ID 60536SD006
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 New
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 Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID SDN002
Out of Country Coverage No
Out of Service Area Coverage No
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) 60536SD0060018-00
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 Direct Standard 5800
Plan Type HMO
Plan Variant Marketing Name Avera Direct Standard 5800
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,700
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $5,800
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 $400
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,100
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID SDS002
Source Name SERFF
Plan ID 60536SD0060018
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
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person 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 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $11600 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5800 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,800
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person 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 Per Group $17800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,900
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 Direct Standard 5800 Health Insurance Plan, 60536SD0060018

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

Frequently Asked Questions(FAQ) about Avera Direct Standard 5800, 60536SD0060018 Health Insurance Plan, 60536SD0060018

  • Does Avera Direct Standard 5800 Health Insurance Plan, 60536SD0060018 support Mail Ordering?

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

  • Does (60536SD0060018) Health Insurance Plan, Variant (60536SD0060018-00) offer Disease Management Programs?

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

    Does (60536SD0060018) Health Insurance Plan, Variant (60536SD0060018-00) have Out Of Country Coverage?

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

    Does (60536SD0060018) Health Insurance Plan, Variant (60536SD0060018-00) 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: 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 (60536SD0060018) Health Insurance Plan, Variant (60536SD0060018-00) 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 Direct Standard 5800 Health Insurance Plan, Variant (60536SD0060018-00) offer Disease Management Programs for Asthma?

    Yes, the Avera Direct Standard 5800 Health Insurance Plan Variant 60536SD0060018-00 offers Disease Management Program for Asthma.

    Does Avera Direct Standard 5800 Health Insurance Plan, Variant (60536SD0060018-00) offer Disease Management Programs for Heart disease?

    Yes, the Avera Direct Standard 5800 Health Insurance Plan Variant 60536SD0060018-00 offers Disease Management Program for Heart disease.

    Does Avera Direct Standard 5800 Health Insurance Plan, Variant (60536SD0060018-00) offer Disease Management Programs for Diabetes?

    Yes, the Avera Direct Standard 5800 Health Insurance Plan Variant 60536SD0060018-00 offers Disease Management Program for Diabetes.

    Does Avera Direct Standard 5800 Health Insurance Plan, Variant (60536SD0060018-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Avera Direct Standard 5800 Health Insurance Plan Variant 60536SD0060018-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Avera Direct Standard 5800 Health Insurance Plan, Variant (60536SD0060018-00) offer Disease Management Programs for Pregnancy?

    Yes, the Avera Direct Standard 5800 Health Insurance Plan Variant 60536SD0060018-00 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