BlueChoice HMO Gold 1750 - 10207VA0380003 Health Insurance Plan
CareFirst BlueChoice, Inc. health insurance plan with the Plan ID 10207VA0380003. The plan is called BlueChoice HMO Gold 1750.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 80.83% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.17% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 10207VA0380003 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Virginia | ||||||||||||||||||
| Health Insurance Issuer | CareFirst BlueChoice, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 10207VA0380003-00 | ||||||||||||||||||
| Provider Network(s) | ['VAN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 10207VA0380003-00 Standard On Exchange Plan - 10207VA0380003-01 |
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| Last Plan Update Date | Wed, 23 Mar 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
BlueChoice HMO Gold 1750 Health Insurance Plan Variant 10207VA0380003-00 Attributes
| Plan Attribute | Value |
|---|---|
| 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 | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | per group not applicable |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $150 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $150 |
| 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, Weight Loss Programs |
| EHB Percent of Total Premium | 0.9927 |
| First Tier Utilization | 100% |
| Formulary ID | VAF004 |
| Formulary URL | URL |
| HIOS Product ID | 10207VA038 |
| Import Date | 3/23/2022 20:00 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 5 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 80.83% |
| Issuer ID | 10207 |
| Issuer Marketplace Marketing Name | CareFirst BlueChoice |
| 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 | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $3500 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $1750 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,750 |
| 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 | VAN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services Only |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 10207VA0380003-00 |
| Plan Marketing Name | BlueChoice HMO Gold 1750 |
| Plan Type | HMO |
| Plan Variant Marketing Name | BlueChoice HMO Gold 1750 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $960 |
| SBC Scenario, Having a Baby, Deductible | $1,750 |
| SBC Scenario, Having a Baby, Limit | $10 |
| SBC Scenario, Having Diabetes, Coinsurance | $56 |
| SBC Scenario, Having Diabetes, Copayment | $660 |
| SBC Scenario, Having Diabetes, Deductible | $1,750 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $90 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,750 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | VAS001 |
| Source Name | SERFF |
| Plan ID | 10207VA0380003 |
| State Code | VA |
| 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 | $13300 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6650 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,650 |
| 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 | Yes |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of BlueChoice HMO Gold 1750 Health Insurance Plan, 10207VA0380003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about BlueChoice HMO Gold 1750, 10207VA0380003 Health Insurance Plan, 10207VA0380003
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Does BlueChoice HMO Gold 1750 Health Insurance Plan, 10207VA0380003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (10207VA0380003) Health Insurance Plan, Variant (10207VA0380003-00) 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, Weight Loss Programs
Does (10207VA0380003) Health Insurance Plan, Variant (10207VA0380003-00) have Out Of Country Coverage?
Yes. Details: Emergency Services Only
Does (10207VA0380003) Health Insurance Plan, Variant (10207VA0380003-00) have Out of Service Area Coverage?
Yes. Details: Emergency Services Only
Does (10207VA0380003) Health Insurance Plan, Variant (10207VA0380003-00) 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, Weight Loss Programs
Does BlueChoice HMO Gold 1750 Health Insurance Plan, Variant (10207VA0380003-00) offer Disease Management Programs for Asthma?
Yes, the BlueChoice HMO Gold 1750 Health Insurance Plan Variant
10207VA0380003-00 offers Disease
Management Program for Asthma.
Does BlueChoice HMO Gold 1750 Health Insurance Plan, Variant (10207VA0380003-00) offer Disease Management Programs for Heart disease?
Yes, the BlueChoice HMO Gold 1750 Health Insurance Plan Variant
10207VA0380003-00 offers Disease
Management Program for Heart disease.
Does BlueChoice HMO Gold 1750 Health Insurance Plan, Variant (10207VA0380003-00) offer Disease Management Programs for Depression?
Yes, the BlueChoice HMO Gold 1750 Health Insurance Plan Variant
10207VA0380003-00 offers Disease
Management Program for Depression.
Does BlueChoice HMO Gold 1750 Health Insurance Plan, Variant (10207VA0380003-00) offer Disease Management Programs for Diabetes?
Yes, the BlueChoice HMO Gold 1750 Health Insurance Plan Variant
10207VA0380003-00 offers Disease
Management Program for Diabetes.
Does BlueChoice HMO Gold 1750 Health Insurance Plan, Variant (10207VA0380003-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the BlueChoice HMO Gold 1750 Health Insurance Plan Variant
10207VA0380003-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does BlueChoice HMO Gold 1750 Health Insurance Plan, Variant (10207VA0380003-00) offer Disease Management Programs for Low back pain?
Yes, the BlueChoice HMO Gold 1750 Health Insurance Plan Variant
10207VA0380003-00 offers Disease
Management Program for Low back pain.
Does BlueChoice HMO Gold 1750 Health Insurance Plan, Variant (10207VA0380003-00) offer Disease Management Programs for Weight loss programs?
Yes, the BlueChoice HMO Gold 1750 Health Insurance Plan Variant
10207VA0380003-00 offers Disease
Management Program for Weight loss programs.
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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