BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs) - 40788TX0460001 Health Insurance Plan

Scott and White Health Plan health insurance plan with the Plan ID 40788TX0460001. The plan is called BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 77.20% (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 22.80% 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 40788TX0460001
Health Insurance Plan Year 2022
State Texas
Health Insurance Issuer Scott and White Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 40788TX0460001-00
Provider Network(s) ['TXN001']
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 Texas 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 - 40788TX0460001-00

Standard On Exchange Plan - 40788TX0460001-01

Open to Indians below 300% FPL - 40788TX0460001-02

Open to Indians above 300% FPL - 40788TX0460001-03

Last Plan Update Date Sat, 23 Oct 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs) Health Insurance Plan Variant 40788TX0460001-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.771964927
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
Dental Only Plan No
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID TXF001
Formulary URL URL
HIOS Product ID 40788TX046
Import Date 10/23/2021 0:47
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 40788
Issuer Marketplace Marketing Name Scott and White Health Plan
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID TXN001
Out of Country Coverage No
Out of Service Area Coverage No
Out of Service Area Coverage Description Emergency Only
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan ID (Standard Component ID with Variant) 40788TX0460001-00
Plan Marketing Name BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs)
Plan Type HMO
Plan Variant Marketing Name BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,800
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $2,300
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $600
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 $1,500
SBC Scenario, Treatment of a Simple Fracture, Deductible $400
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID TXS001
Source Name HIOS
Plan ID 40788TX0460001
State Code TX
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 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $4600 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $2300 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $2,300
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 $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 BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs) Health Insurance Plan, 40788TX0460001

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

Frequently Asked Questions(FAQ) about BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs), 40788TX0460001 Health Insurance Plan, 40788TX0460001

  • Does BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs) Health Insurance Plan, 40788TX0460001 support Mail Ordering?

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

  • Does (40788TX0460001) Health Insurance Plan, Variant (40788TX0460001-00) offer Disease Management Programs?

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

    Does (40788TX0460001) Health Insurance Plan, Variant (40788TX0460001-00) have Out Of Country Coverage?

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

    Does (40788TX0460001) Health Insurance Plan, Variant (40788TX0460001-00) 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 Only

    Does (40788TX0460001) Health Insurance Plan, Variant (40788TX0460001-00) offer Disease Management Programs?

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

    Does BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs) Health Insurance Plan, Variant (40788TX0460001-00) offer Disease Management Programs for Asthma?

    Yes, the BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs) Health Insurance Plan Variant 40788TX0460001-00 offers Disease Management Program for Asthma.

    Does BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs) Health Insurance Plan, Variant (40788TX0460001-00) offer Disease Management Programs for Heart disease?

    Yes, the BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs) Health Insurance Plan Variant 40788TX0460001-00 offers Disease Management Program for Heart disease.

    Does BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs) Health Insurance Plan, Variant (40788TX0460001-00) offer Disease Management Programs for Diabetes?

    Yes, the BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs) Health Insurance Plan Variant 40788TX0460001-00 offers Disease Management Program for Diabetes.

    Does BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs) Health Insurance Plan, Variant (40788TX0460001-00) offer Disease Management Programs for Pregnancy?

    Yes, the BSW Elite Gold HMO 001 ($0 Preventive Care and Preventive Rx Drugs) Health Insurance Plan Variant 40788TX0460001-00 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