"BUSINESS YEAR","STATE CODE","ISSUER NAME","ISSUER ID","SOURCE NAME","VERSION NUMBER","IMPORT DATE","BENEFIT PACKAGE ID","MARKET COVERAGE","DENTAL ONLY PLAN",TIN,"STANDARD COMPONENT ID","PLAN MARKETING NAME","HIOS PRODUCT ID",HPID,"NETWORK ID","SERVICE AREA ID","FORMULARY ID","IS IT A NEW PLAN","PLAN TYPE","METAL LEVEL","UNIQUE PLAN DESIGN","QHP NONQHP TYPE ID","IS NOTICE REQUIRED FOR PREGNACY","IS REFERRAL REQUIRED FOR SPECIALIST","SPECIALIST REQUIRING REFERRAL","PLAN LEVEL EXCLUSIONS","IS HSA ELIGIBLE","HSA OR HRA EMPLOYER CONTRIBUTION","HSA OR HRA EMPLOYER CONTRIBUTION AMOUNT","CHILD ONLY OFFERING","CHILD ONLY PLAN ID","WELLNESS PROGRAM OFFERED","DISEASE MANAGEMENT PROGRAMS OFFERED","EHB PEDIATRIC DENTAL APPORTIONMENT QUANTITY","IS GUARANTEED RATE?","SPECIALITY DRUG MAXIMUM COINSURANCE","INPATIENT COPAYMENT MAXIMUM DAYS","BEGIN PRIMARY CARE COST SHARING AFTER NUMBER OF VISITS","BEGIN PRIMARY CARE DEDUCTIBLE COINSURANCE AFTER NUMBER OF COPAYS","PLAN EFFECTIVE DATE","PLAN EXPIRATION DATE","OUT OF COUNTRY COVERAGE","OUT OF COUNTRY COVERAGE DESCRIPTION","OUT OF SERVICE AREA COVERAGE","OUT OF SERVICE AREA COVERAGE DESCRIPTION","NATIONAL NETWORK","URL FOR SUMMARY OF BENEFITS COVERAGE","URL FOR ENROLLMENT PAYMENT","PLAN BROCHURE","FORMULARY URL","PLAN ID","CSR VARIATION TYPE","ISSUER ACTUARIAL VALUE","AV CALCULATOR OUTPUT NUMBER","MEDICAL DRUG DEDUCTIBLES INTEGRATED","MEDICAL DRUG MAXIMUM OUT OF POCKET INTEGRATED","MULTIPLE NETWORK TIERS","FIRST TIER UTILIZATION","SECOND TIER UTILIZATION","MEHB INN TIER 1 INDIVIDUAL MOOP","MEHB INN TIER 1 FAMILY MOOP","MEHB INN TIER 2 INDIVIDUAL MOOP","MEHB INN TIER 2 FAMILY MOOP","MEHB OUT OF NET INDIVIDUAL MOOP","MEHB OUT OF NET FAMILY MOOP","MEHB COMB INN OON INDIVIDUAL MOOP","MEHB COMB INN OON FAMILY MOOP","DEHB INN TIER 1 INDIVIDUAL MOOP","DEHB INN TIER 2 INDIVIDUAL MOOP","DEHB INN TIER 1 FAMILY MOOP","DEHB INN TIER 2 FAMILY MOOP","DEHB OUT OF NET INDIVIDUAL MOOP","DEHB OUT OF NET FAMILY MOOP","DEHB COMB INN OON INDIVIDUAL MOOP","DEHB COMB INN OON FAMILY MOOP","TEHB INN TIER 1 INDIVIDUAL MOOP","TEHB INN TIER 1 FAMILY MOOP","TEHB INN TIER 2 INDIVIDUAL MOOP","TEHB INN TIER 2 FAMILY MOOP","TEHB OUT OF NET INDIVIDUAL MOOP","TEHB OUT OF NET FAMILY MOOP","TEHB COMB INN OON INDIVIDUAL MOOP","TEHB COMB INN OON FAMILY MOOP","MEHB DED INN TIER1 INDIVIDUAL","MEHB DED INN TIER1 FAMILY","MEHB DED INN TIER1 COINSURNACE","MEHB DED INN TIER2 INDIVIDUAL","MEHB DED INN TIER2 FAMILY","MEHB DED INN TIER2 COINSURANCE","MEHB DED OUT OF NET INDIVIDUAL","MEHB DED OUT OF NET FAMILY","MEHB DED COMB INN OON INDIVIDUAL","MEHB DED COMB INN OON FAMILY","DEHB DED INN TIER1 INDIVIDUAL","DEHB DED INN TIER1 FAMILY","DEHB DED INN TIER1 COINSURNACE","DEHB DED INN TIER2 INDIVIDUAL","DEHB DED INN TIER2 FAMILY","DEHB DED INN TIER2 COINSURANCE","DEHB DED OUT OF NET INDIVIDUAL","DEHB DED OUT OF NET FAMILY","DEHB DED COMB INN OON INDIVIDUAL","DEHB DED COMB INN OON FAMILY","TEHB DED INN TIER 1 INDIVIDUAL","TEHB DED INN TIER 1 FAMILY","TEHB DED INN TIER 1 COINSURANCE","TEHB DED INN TIER 2 INDIVIDUAL","TEHB DED INN TIER 2 FAMILY","TEHB DED INN TIER 2 COINSURANCE","TEHB DED OUT OF NET INDIVIDUAL","TEHB DED OUT OF NET FAMILY","TEHB DED OUT COMB INN OON INDIVIDUAL","TEHB DED OUT COMB INN OON FAMILY","SBC HAVING A BABY DEDUCTIBLE","SBC HAVING A BABY COPAYMENT","SBC HAVING A BABY COINSURANCE","SBC HAVING A BABY LIMIT","SBC HAVING DIABETES DEDUCTIBLE","SBC HAVING  DIABETES COPAYMENT","SBC HAVING DIABETES COINSURANCE","SBC HAVING DIABETES LIMIT","EHB PERCENT PREMIUM","PLAN DESIGN TYPE","INSURANCE PLAN COMPOSITE PREMIUM AVAILABLE INDICATOR","PLAN VARIANT MARKETING NAME","SBC HAVING SIMPLE FRACTURE DEDUCTIBLE","SBC HAVING SIMPLE FRACTURE COPAYMENT","SBC HAVING SIMPLE FRACTURE COINSURANCE","SBC HAVING SIMPLE FRACTURE LIMIT"
2024,ID,,10204,SERFF,1,2/12/2024,,Individual,Yes,,10204ID0070002,"Guardian Essentials for Families and Individuals ",10204ID007,,IDN001,IDS001,,New,PPO,Low,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,No,,Yes,"Coverage is provided outside of the Service Area.",Yes,,,,,10204ID0070002-01,"Standard Low On Exchange Plan",,,,,No,100%,,"$400 ","$400 per person | $800 per group",,,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"$50 ","$50 per person | per group not applicable",,,,,"$75 ","$75 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Guardian Essentials for Families and Individuals ",,,,
2024,ID,,10204,SERFF,1,2/12/2024,,Individual,Yes,,10204ID0080002,"Guardian Select for Families and Individuals ",10204ID008,,IDN001,IDS001,,New,PPO,Low,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,No,,Yes,"Coverage is provided outside of the Service Area.",Yes,,,,,10204ID0080002-01,"Standard Low On Exchange Plan",,,,,No,100%,,"$400 ","$400 per person | $800 per group",,,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"$50 ","$50 per person | per group not applicable",,,,,"$75 ","$75 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Guardian Select for Families and Individuals ",,,,
2024,ID,,10204,SERFF,1,2/12/2024,,Individual,Yes,,10204ID0090002,"Guardian Basics for Families and Individuals ",10204ID009,,IDN001,IDS001,,New,PPO,Low,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,No,,Yes,"Coverage is provided outside of the Service Area.",Yes,,,,,10204ID0090002-01,"Standard Low On Exchange Plan",,,,,No,100%,,"$400 ","$400 per person | $800 per group",,,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"$50 ","$50 per person | per group not applicable",,,,,"$75 ","$75 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Guardian Basics for Families and Individuals ",,,,
2024,ID,,10204,SERFF,1,2/12/2024,,Individual,Yes,,10204ID0100002,"Guardian Preventive Plus for Families and Individuals ",10204ID010,,IDN001,IDS001,,New,PPO,Low,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,No,,Yes,"Coverage is provided outside of the Service Area.",Yes,,,,,10204ID0100002-01,"Standard Low On Exchange Plan",,,,,No,100%,,"$400 ","$400 per person | $800 per group",,,"Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"$50 ","$50 per person | per group not applicable",,,,,"$75 ","$75 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Guardian Preventive Plus for Families and Individuals ",,,,
2024,ID,,17859,SERFF,1,2/12/2024,,Individual,Yes,,17859ID0020003,"BESTOne Advantage Gold",17859ID002,,IDN001,IDS001,,Existing,PPO,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,No,,Yes,Full,Yes,,,,,17859ID0020003-01,"Standard High On Exchange Plan",,,,,No,100%,,"$350 ","$350 per person | $700 per group",,,"$700 ","$700 per person | $1400 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"Not Applicable","per person not applicable | per group not applicable","$50 ","$50 per person | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"BESTOne Advantage Gold",,,,
2024,ID,,17859,SERFF,1,2/12/2024,,Individual,Yes,,17859ID0020006,"BESTOne Basic Silver",17859ID002,,IDN001,IDS001,,Existing,PPO,Low,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,No,,Yes,"Full ",Yes,,,,,17859ID0020006-01,"Standard Low On Exchange Plan",,,,,No,100%,,"$350 ","$350 per person | $700 per group",,,"$700 ","$700 per person | $1400 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"$75 ","$75 per person | per group not applicable",,,,,"$100 ","$100 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"BESTOne Basic Silver",,,,
2024,ID,,17859,SERFF,1,2/12/2024,,Individual,Yes,,17859ID0020007,"BESTOne Gold  Plus",17859ID002,,IDN001,IDS001,,Existing,PPO,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,No,,Yes,"Full ",Yes,,,,,17859ID0020007-01,"Standard High On Exchange Plan",,,,,No,100%,,"$350 ","$350 per person | $700 per group",,,"$700 ","$700 per person | $1400 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"Not Applicable","per person not applicable | per group not applicable","$50 ","$50 per person | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"BESTOne Gold  Plus",,,,
2024,ID,,17859,SERFF,1,2/12/2024,,Individual,Yes,,17859ID0020008,"BESTOne Base Silver",17859ID002,,IDN001,IDS001,,Existing,PPO,Low,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,No,,Yes,"Full ",Yes,,,,,17859ID0020008-01,"Standard Low On Exchange Plan",,,,,No,100%,,"$350 ","$350 per person | $700 per group",,,"$700 ","$700 per person | $1400 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"$75 ","$75 per person | per group not applicable",,,,,"$100 ","$100 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"BESTOne Base Silver",,,,
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010005,"Select Health SLHP Silver 3000",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010005-01,"Standard Silver On Exchange Plan",,0.701960823,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$400 ","$4,200 ","$60 ","$1,100 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 3000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010005,"Select Health SLHP Silver 3000",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010005-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SLHP Silver 3000","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010005,"Select Health SLHP Silver 3000",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010005-03,"Limited Cost Sharing Plan Variation",,0.701960823,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$400 ","$4,200 ","$60 ","$1,100 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 3000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010005,"Select Health SLHP Silver 3000",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010005-04,"73% AV Level Silver Plan",,0.737329991,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,100 ","$7100 per person | $14200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,100 ","$1100 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$400 ","$3,400 ","$60 ","$800 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 3000","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010005,"Select Health SLHP Silver 3000",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010005-05,"87% AV Level Silver Plan",,0.871821489,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,600 ","$2600 per person | $5200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$200 ","$200 per person | per group not applicable",,,,,,,,,,,"$500 ","$300 ","$1,800 ","$60 ","$500 ","$400 ","$90 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 3000","$500 ","$900 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010005,"Select Health SLHP Silver 3000",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010005-06,"94% AV Level Silver Plan",,0.948241329,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,200 ","$1200 per person | $2400 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$200 ","$1,000 ","$60 ","$0 ","$100 ","$200 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 3000","$0 ","$500 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010007,"Select Health SLHP Gold 1500 - no deductible for office visits",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010007-01,"Standard Gold On Exchange Plan",,0.794024917,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | $3000 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | per group not applicable",,,,,,,,,,,"$1,500 ","$10 ","$2,000 ","$60 ","$800 ","$300 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Gold 1500 - no deductible for office visits","$1,500 ","$500 ","$80 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010007,"Select Health SLHP Gold 1500 - no deductible for office visits",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010007-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SLHP Gold 1500 - no deductible for office visits","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010007,"Select Health SLHP Gold 1500 - no deductible for office visits",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010007-03,"Limited Cost Sharing Plan Variation",,0.794024917,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | $3000 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | per group not applicable",,,,,,,,,,,"$1,500 ","$10 ","$2,000 ","$60 ","$800 ","$300 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Gold 1500 - no deductible for office visits","$1,500 ","$500 ","$80 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010009,"Select Health SLHP Silver 4000 - $0 copay for PCP visits ",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010009-01,"Standard Silver On Exchange Plan",,0.708801775,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,000 ","$4000 per person | $8000 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$4,000 ","$600 ","$3,000 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 4000 - $0 copay for PCP visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010009,"Select Health SLHP Silver 4000 - $0 copay for PCP visits ",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010009-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SLHP Silver 4000 - $0 copay for PCP visits ","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010009,"Select Health SLHP Silver 4000 - $0 copay for PCP visits ",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010009-03,"Limited Cost Sharing Plan Variation",,0.708801775,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,000 ","$4000 per person | $8000 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$4,000 ","$600 ","$3,000 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 4000 - $0 copay for PCP visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010009,"Select Health SLHP Silver 4000 - $0 copay for PCP visits ",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010009-04,"73% AV Level Silver Plan",,0.732483378,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,600 ","$3600 per person | $7200 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,400 ","$1400 per person | per group not applicable",,,,,,,,,,,"$3,600 ","$600 ","$3,100 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 4000 - $0 copay for PCP visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010009,"Select Health SLHP Silver 4000 - $0 copay for PCP visits ",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010009-05,"87% AV Level Silver Plan",,0.874462146,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,000 ","$3000 per person | $6000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$700 ","$700 per person | $1400 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$700 ","$300 ","$2,000 ","$60 ","$700 ","$400 ","$30 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 4000 - $0 copay for PCP visits ","$700 ","$900 ","$200 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010009,"Select Health SLHP Silver 4000 - $0 copay for PCP visits ",26002ID001,,IDN001,IDS001,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010009-06,"94% AV Level Silver Plan",,0.949404697,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,800 ","$1800 per person | $3600 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$1,800 ","$60 ","$0 ","$30 ","$200 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 4000 - $0 copay for PCP visits ","$0 ","$500 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010011,"Select Health SLHP Bronze 8000",26002ID001,,IDN001,IDS001,IDF009,Existing,PPO,Bronze,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010011-01,"Standard Bronze On Exchange Plan",,0.597244125,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$8,000 ","$8000 per person | $16000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,700 ","$1700 per person | per group not applicable",,,,,,,,,,,"$8,000 ","$0 ","$1,100 ","$60 ","$1,900 ","$300 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Bronze 8000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010011,"Select Health SLHP Bronze 8000",26002ID001,,IDN001,IDS001,IDF009,Existing,PPO,Bronze,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010011-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SLHP Bronze 8000","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010011,"Select Health SLHP Bronze 8000",26002ID001,,IDN001,IDS001,IDF009,Existing,PPO,Bronze,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010011-03,"Limited Cost Sharing Plan Variation",,0.597244125,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$8,000 ","$8000 per person | $16000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,700 ","$1700 per person | per group not applicable",,,,,,,,,,,"$8,000 ","$0 ","$1,100 ","$60 ","$1,900 ","$300 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Bronze 8000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010012,"Select Health SLHP Silver 4500  - no deductible for office visits",26002ID001,,IDN001,IDS001,IDF012,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010012-01,"Standard Silver On Exchange Plan",,0.718666721,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$700 ","$0 ","$60 ","$800 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 4500  - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010012,"Select Health SLHP Silver 4500  - no deductible for office visits",26002ID001,,IDN001,IDS001,IDF012,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010012-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SLHP Silver 4500  - no deductible for office visits","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010012,"Select Health SLHP Silver 4500  - no deductible for office visits",26002ID001,,IDN001,IDS001,IDF012,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010012-03,"Limited Cost Sharing Plan Variation",,0.718666721,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$700 ","$0 ","$60 ","$800 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 4500  - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010012,"Select Health SLHP Silver 4500  - no deductible for office visits",26002ID001,,IDN001,IDS001,IDF012,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010012-04,"73% AV Level Silver Plan",,0.739651212,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$700 ","$0 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 4500  - no deductible for office visits","$2,100 ","$300 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010012,"Select Health SLHP Silver 4500  - no deductible for office visits",26002ID001,,IDN001,IDS001,IDF012,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010012-05,"87% AV Level Silver Plan",,0.879599364,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,150 ","$3150 per person | $6300 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$1,100 ","$1100 per person | $2200 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$1,100 ","$1,300 ","$400 ","$60 ","$800 ","$200 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 4500  - no deductible for office visits","$1,100 ","$900 ","$90 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010012,"Select Health SLHP Silver 4500  - no deductible for office visits",26002ID001,,IDN001,IDS001,IDF012,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010012-06,"94% AV Level Silver Plan",,0.947926542,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$500 ","$300 ","$60 ","$0 ","$30 ","$200 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver 4500  - no deductible for office visits","$0 ","$900 ","$60 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010018,"Select Health SLHP Exp Bronze 8000 HSA Qualified ",26002ID001,,IDN001,IDS001,IDF010,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010018-01,"Standard Bronze On Exchange Plan",,0.629227715,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$8,000 ","per person not applicable | $16000 per group",0.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","$8,000 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Exp Bronze 8000 HSA Qualified ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010018,"Select Health SLHP Exp Bronze 8000 HSA Qualified ",26002ID001,,IDN001,IDS001,IDF010,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010018-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SLHP Exp Bronze 8000  ","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010018,"Select Health SLHP Exp Bronze 8000 HSA Qualified ",26002ID001,,IDN001,IDS001,IDF010,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010018-03,"Limited Cost Sharing Plan Variation",,0.629227715,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$8,000 ","per person not applicable | $16000 per group",0.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","$8,000 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Exp Bronze 8000  ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010028,"Select Health SLHP Exp Bronze 4500",26002ID001,,IDN001,IDS001,IDF014,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010028-01,"Standard Bronze On Exchange Plan",,0.642908255,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,700 ","$1700 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$10 ","$4,000 ","$60 ","$1,200 ","$700 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Exp Bronze 4500","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010028,"Select Health SLHP Exp Bronze 4500",26002ID001,,IDN001,IDS001,IDF014,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010028-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SLHP Exp Bronze 4500","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010028,"Select Health SLHP Exp Bronze 4500",26002ID001,,IDN001,IDS001,IDF014,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010028-03,"Limited Cost Sharing Plan Variation",,0.642908255,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,700 ","$1700 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$10 ","$4,000 ","$60 ","$1,200 ","$700 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Exp Bronze 4500","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010029,"Select Health SLHP Exp Bronze 6000 - no deductible for PCP visits ",26002ID001,,IDN001,IDS001,IDF014,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010029-01,"Standard Bronze On Exchange Plan",,0.647698034,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$6,000 ","$6000 per person | $12000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | per group not applicable",,,,,,,,,,,"$6,000 ","$600 ","$2,500 ","$60 ","$1,100 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Exp Bronze 6000 - no deductible for PCP visits ","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010029,"Select Health SLHP Exp Bronze 6000 - no deductible for PCP visits ",26002ID001,,IDN001,IDS001,IDF014,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010029-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SLHP Exp Bronze 6000 - no deductible for PCP visits ","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010029,"Select Health SLHP Exp Bronze 6000 - no deductible for PCP visits ",26002ID001,,IDN001,IDS001,IDF014,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010029-03,"Limited Cost Sharing Plan Variation",,0.647698034,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$6,000 ","$6000 per person | $12000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | per group not applicable",,,,,,,,,,,"$6,000 ","$600 ","$2,500 ","$60 ","$1,100 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Exp Bronze 6000 - no deductible for PCP visits ","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010033,"Select Health SLHP Exp Bronze 9400 - no deductible for office visits",26002ID001,,IDN001,IDS001,IDF011,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010033-01,"Standard Bronze On Exchange Plan",,0.645948369,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",0.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","$8,800 ","$600 ","$0 ","$60 ","$800 ","$1,000 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Exp Bronze 9400 - no deductible for office visits","$2,100 ","$600 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010033,"Select Health SLHP Exp Bronze 9400 - no deductible for office visits",26002ID001,,IDN001,IDS001,IDF011,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010033-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SLHP Exp Bronze 9400 - no deductible for office visits","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010033,"Select Health SLHP Exp Bronze 9400 - no deductible for office visits",26002ID001,,IDN001,IDS001,IDF011,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010033-03,"Limited Cost Sharing Plan Variation",,0.645948369,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",0.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","$8,800 ","$600 ","$0 ","$60 ","$800 ","$1,000 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Exp Bronze 9400 - no deductible for office visits","$2,100 ","$600 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010036,"Select Health SLHP Silver Copay Plan",26002ID001,,IDN001,IDS001,IDF013,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010036-01,"Standard Silver On Exchange Plan",,0.710768569,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | per group not applicable",,,,,,,,,,,"$0 ","$3,600 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver Copay Plan","$0 ","$1,700 ","$100 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010036,"Select Health SLHP Silver Copay Plan",26002ID001,,IDN001,IDS001,IDF013,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010036-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SLHP Silver Copay Plan","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010036,"Select Health SLHP Silver Copay Plan",26002ID001,,IDN001,IDS001,IDF013,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010036-03,"Limited Cost Sharing Plan Variation",,0.710768569,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | per group not applicable",,,,,,,,,,,"$0 ","$3,600 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver Copay Plan","$0 ","$1,700 ","$100 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010036,"Select Health SLHP Silver Copay Plan",26002ID001,,IDN001,IDS001,IDF013,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010036-04,"73% AV Level Silver Plan",,0.73950388,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | per group not applicable",,,,,,,,,,,"$0 ","$3,500 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver Copay Plan","$0 ","$1,700 ","$100 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010036,"Select Health SLHP Silver Copay Plan",26002ID001,,IDN001,IDS001,IDF013,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010036-05,"87% AV Level Silver Plan",,0.878049635,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,000 ","$3000 per person | $6000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$700 ","$700 per person | per group not applicable",,,,,,,,,,,"$0 ","$1,900 ","$0 ","$60 ","$0 ","$1,100 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver Copay Plan","$0 ","$1,300 ","$70 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010036,"Select Health SLHP Silver Copay Plan",26002ID001,,IDN001,IDS001,IDF013,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010036-06,"94% AV Level Silver Plan",,0.94360662,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",10.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",10.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$1,000 ","$0 ","$60 ","$0 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SLHP Silver Copay Plan","$0 ","$700 ","$20 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010037,"BrightPath Gold 1000 - no deductible for office visits",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010037-01,"Standard Gold On Exchange Plan",,0.790630058,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | $2000 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$1,000 ","$10 ","$2,100 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Gold 1000 - no deductible for office visits","$1,000 ","$1,000 ","$80 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010037,"BrightPath Gold 1000 - no deductible for office visits",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010037-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"BrightPath Gold 1000 - no deductible for office visits","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010037,"BrightPath Gold 1000 - no deductible for office visits",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010037-03,"Limited Cost Sharing Plan Variation",,0.790630058,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | $2000 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$1,000 ","$10 ","$2,100 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Gold 1000 - no deductible for office visits","$1,000 ","$1,000 ","$80 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010039,"BrightPath Silver 4000 - $0 Copay for PCP visits ",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010039-01,"Standard Silver On Exchange Plan",,0.708801775,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,000 ","$4000 per person | $8000 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$4,000 ","$600 ","$3,000 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 4000 - $0 Copay for PCP visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010039,"BrightPath Silver 4000 - $0 Copay for PCP visits ",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010039-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"BrightPath Silver 4000 - $0 Copay for PCP visits ","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010039,"BrightPath Silver 4000 - $0 Copay for PCP visits ",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010039-03,"Limited Cost Sharing Plan Variation",,0.708801775,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,000 ","$4000 per person | $8000 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$4,000 ","$600 ","$3,000 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 4000 - $0 Copay for PCP visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010039,"BrightPath Silver 4000 - $0 Copay for PCP visits ",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010039-04,"73% AV Level Silver Plan",,0.732483378,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,600 ","$3600 per person | $7200 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,400 ","$1400 per person | per group not applicable",,,,,,,,,,,"$3,600 ","$600 ","$3,100 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 4000 - $0 Copay for PCP visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010039,"BrightPath Silver 4000 - $0 Copay for PCP visits ",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010039-05,"87% AV Level Silver Plan",,0.874462146,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,000 ","$3000 per person | $6000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$700 ","$700 per person | $1400 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$700 ","$300 ","$2,000 ","$60 ","$700 ","$400 ","$30 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 4000 - $0 Copay for PCP visits ","$700 ","$900 ","$200 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010039,"BrightPath Silver 4000 - $0 Copay for PCP visits ",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010039-06,"94% AV Level Silver Plan",,0.949404697,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,800 ","$1800 per person | $3600 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$1,800 ","$60 ","$0 ","$30 ","$200 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 4000 - $0 Copay for PCP visits ","$0 ","$500 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010040,"BrightPath Exp Bronze 6000 - no deductible for office visits ",26002ID001,,IDN002,IDS002,IDF014,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010040-01,"Standard Bronze On Exchange Plan",,0.647698034,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$6,000 ","$6000 per person | $12000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | per group not applicable",,,,,,,,,,,"$6,000 ","$600 ","$2,500 ","$60 ","$1,100 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Exp Bronze 6000 - no deductible for office visits ","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010040,"BrightPath Exp Bronze 6000 - no deductible for office visits ",26002ID001,,IDN002,IDS002,IDF014,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010040-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"BrightPath Exp Bronze 6000 - no deductible for office visits ","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010040,"BrightPath Exp Bronze 6000 - no deductible for office visits ",26002ID001,,IDN002,IDS002,IDF014,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010040-03,"Limited Cost Sharing Plan Variation",,0.647698034,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$6,000 ","$6000 per person | $12000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | per group not applicable",,,,,,,,,,,"$6,000 ","$600 ","$2,500 ","$60 ","$1,100 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Exp Bronze 6000 - no deductible for office visits ","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010045,"BrightPath Silver 3000",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010045-01,"Standard Silver On Exchange Plan",,0.701960823,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$400 ","$4,200 ","$60 ","$1,100 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 3000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010045,"BrightPath Silver 3000",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010045-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"BrightPath Silver 3000","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010045,"BrightPath Silver 3000",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010045-03,"Limited Cost Sharing Plan Variation",,0.701960823,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$400 ","$4,200 ","$60 ","$1,100 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 3000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010045,"BrightPath Silver 3000",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010045-04,"73% AV Level Silver Plan",,0.737329991,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,100 ","$7100 per person | $14200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,100 ","$1100 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$400 ","$3,400 ","$60 ","$800 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 3000","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010045,"BrightPath Silver 3000",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010045-05,"87% AV Level Silver Plan",,0.871821489,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,600 ","$2600 per person | $5200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$200 ","$200 per person | per group not applicable",,,,,,,,,,,"$500 ","$300 ","$1,800 ","$60 ","$500 ","$400 ","$90 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 3000","$500 ","$900 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010045,"BrightPath Silver 3000",26002ID001,,IDN002,IDS002,IDF008,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010045-06,"94% AV Level Silver Plan",,0.948241329,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,200 ","$1200 per person | $2400 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$200 ","$1,000 ","$60 ","$0 ","$100 ","$200 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 3000","$0 ","$500 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010046,"BrightPath Exp Bronze 4500",26002ID001,,IDN002,IDS002,IDF014,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010046-01,"Standard Bronze On Exchange Plan",,0.642908255,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,700 ","$1700 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$10 ","$4,000 ","$60 ","$1,200 ","$700 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Exp Bronze 4500","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010046,"BrightPath Exp Bronze 4500",26002ID001,,IDN002,IDS002,IDF014,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010046-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"BrightPath Exp Bronze 4500","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010046,"BrightPath Exp Bronze 4500",26002ID001,,IDN002,IDS002,IDF014,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010046-03,"Limited Cost Sharing Plan Variation",,0.642908255,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,700 ","$1700 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$10 ","$4,000 ","$60 ","$1,200 ","$700 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Exp Bronze 4500","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010047,"BrightPath Silver 4500 - no deductible for office visits",26002ID001,,IDN002,IDS002,IDF012,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010047-01,"Standard Silver On Exchange Plan",,0.718666721,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$700 ","$0 ","$60 ","$800 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 4500 - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010047,"BrightPath Silver 4500 - no deductible for office visits",26002ID001,,IDN002,IDS002,IDF012,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010047-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"BrightPath Silver 4500 - no deductible for office visits","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010047,"BrightPath Silver 4500 - no deductible for office visits",26002ID001,,IDN002,IDS002,IDF012,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010047-03,"Limited Cost Sharing Plan Variation",,0.718666721,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$700 ","$0 ","$60 ","$800 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 4500 - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010047,"BrightPath Silver 4500 - no deductible for office visits",26002ID001,,IDN002,IDS002,IDF012,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010047-04,"73% AV Level Silver Plan",,0.739651212,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$700 ","$0 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 4500 - no deductible for office visits","$2,100 ","$300 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010047,"BrightPath Silver 4500 - no deductible for office visits",26002ID001,,IDN002,IDS002,IDF012,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010047-05,"87% AV Level Silver Plan",,0.879599364,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,150 ","$3150 per person | $6300 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$1,100 ","$1100 per person | $2200 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$1,100 ","$1,300 ","$400 ","$60 ","$800 ","$200 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 4500 - no deductible for office visits","$1,100 ","$900 ","$90 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010047,"BrightPath Silver 4500 - no deductible for office visits",26002ID001,,IDN002,IDS002,IDF012,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010047-06,"94% AV Level Silver Plan",,0.947926542,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$500 ","$300 ","$60 ","$0 ","$30 ","$200 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver 4500 - no deductible for office visits","$0 ","$900 ","$60 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010048,"BrightPath Silver Copay Plan",26002ID001,,IDN002,IDS002,IDF013,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010048-01,"Standard Silver On Exchange Plan",,0.710768569,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | per group not applicable",,,,,,,,,,,"$0 ","$3,600 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver Copay Plan","$0 ","$1,700 ","$100 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010048,"BrightPath Silver Copay Plan",26002ID001,,IDN002,IDS002,IDF013,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010048-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"BrightPath Silver Copay Plan","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010048,"BrightPath Silver Copay Plan",26002ID001,,IDN002,IDS002,IDF013,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010048-03,"Limited Cost Sharing Plan Variation",,0.710768569,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | per group not applicable",,,,,,,,,,,"$0 ","$3,600 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver Copay Plan","$0 ","$1,700 ","$100 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010048,"BrightPath Silver Copay Plan",26002ID001,,IDN002,IDS002,IDF013,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010048-04,"73% AV Level Silver Plan",,0.73950388,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | per group not applicable",,,,,,,,,,,"$0 ","$3,500 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver Copay Plan","$0 ","$1,700 ","$100 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010048,"BrightPath Silver Copay Plan",26002ID001,,IDN002,IDS002,IDF013,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010048-05,"87% AV Level Silver Plan",,0.878049635,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,000 ","$3000 per person | $6000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$700 ","$700 per person | per group not applicable",,,,,,,,,,,"$0 ","$1,900 ","$0 ","$60 ","$0 ","$1,100 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver Copay Plan","$0 ","$1,300 ","$70 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010048,"BrightPath Silver Copay Plan",26002ID001,,IDN002,IDS002,IDF013,Existing,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010048-06,"94% AV Level Silver Plan",,0.94360662,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",10.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",10.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$1,000 ","$0 ","$60 ","$0 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Silver Copay Plan","$0 ","$700 ","$20 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010049,"BrightPath Exp Bronze 8000 HSA Qualified ",26002ID001,,IDN002,IDS002,IDF010,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010049-01,"Standard Bronze On Exchange Plan",,0.629227715,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$8,000 ","per person not applicable | $16000 per group",0.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","$8,000 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Exp Bronze 8000 HSA Qualified ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010049,"BrightPath Exp Bronze 8000 HSA Qualified ",26002ID001,,IDN002,IDS002,IDF010,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010049-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"BrightPath Exp Bronze 8000 ","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010049,"BrightPath Exp Bronze 8000 HSA Qualified ",26002ID001,,IDN002,IDS002,IDF010,Existing,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010049-03,"Limited Cost Sharing Plan Variation",,0.629227715,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$8,000 ","per person not applicable | $16000 per group",0.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","$8,000 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"BrightPath Exp Bronze 8000","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010050,"Select Health SAHA Gold 1000 - no deductible for office visits",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010050-01,"Standard Gold On Exchange Plan",,0.790630058,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | $2000 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$1,000 ","$10 ","$2,100 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Gold 1000 - no deductible for office visits","$1,000 ","$1,000 ","$80 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010050,"Select Health SAHA Gold 1000 - no deductible for office visits",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010050-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SAHA Gold 1000 - no deductible for office visits","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010050,"Select Health SAHA Gold 1000 - no deductible for office visits",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010050-03,"Limited Cost Sharing Plan Variation",,0.790630058,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | $2000 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$1,000 ","$10 ","$2,100 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Gold 1000 - no deductible for office visits","$1,000 ","$1,000 ","$80 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010051,"Select Health SAHA Silver 4000 - $0 copay for PCP visits ",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010051-01,"Standard Silver On Exchange Plan",,0.708801775,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,000 ","$4000 per person | $8000 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$4,000 ","$600 ","$3,000 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 4000 - $0 copay for PCP visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010051,"Select Health SAHA Silver 4000 - $0 copay for PCP visits ",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010051-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SAHA Silver 4000 - $0 copay for PCP visits ","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010051,"Select Health SAHA Silver 4000 - $0 copay for PCP visits ",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010051-03,"Limited Cost Sharing Plan Variation",,0.708801775,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,000 ","$4000 per person | $8000 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$4,000 ","$600 ","$3,000 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 4000 - $0 copay for PCP visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010051,"Select Health SAHA Silver 4000 - $0 copay for PCP visits ",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010051-04,"73% AV Level Silver Plan",,0.732483378,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,600 ","$3600 per person | $7200 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,400 ","$1400 per person | per group not applicable",,,,,,,,,,,"$3,600 ","$600 ","$3,100 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 4000 - $0 copay for PCP visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010051,"Select Health SAHA Silver 4000 - $0 copay for PCP visits ",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010051-05,"87% AV Level Silver Plan",,0.874462146,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,000 ","$3000 per person | $6000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$700 ","$700 per person | $1400 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$700 ","$300 ","$2,000 ","$60 ","$700 ","$400 ","$30 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 4000 - $0 copay for PCP visits ","$700 ","$900 ","$200 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010051,"Select Health SAHA Silver 4000 - $0 copay for PCP visits ",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010051-06,"94% AV Level Silver Plan",,0.949404697,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,800 ","$1800 per person | $3600 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$1,800 ","$60 ","$0 ","$30 ","$200 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 4000 - $0 copay for PCP visits ","$0 ","$500 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010052,"Select Health SAHA Exp Bronze 6000 - no deductible for PCP visits ",26002ID001,,IDN003,IDS003,IDF014,New,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010052-01,"Standard Bronze On Exchange Plan",,0.647698034,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$6,000 ","$6000 per person | $12000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | per group not applicable",,,,,,,,,,,"$6,000 ","$600 ","$2,500 ","$60 ","$1,100 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Exp Bronze 6000 - no deductible for PCP visits ","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010052,"Select Health SAHA Exp Bronze 6000 - no deductible for PCP visits ",26002ID001,,IDN003,IDS003,IDF014,New,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010052-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SAHA Exp Bronze 6000 - no deductible for PCP visits ","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010052,"Select Health SAHA Exp Bronze 6000 - no deductible for PCP visits ",26002ID001,,IDN003,IDS003,IDF014,New,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010052-03,"Limited Cost Sharing Plan Variation",,0.647698034,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$6,000 ","$6000 per person | $12000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | per group not applicable",,,,,,,,,,,"$6,000 ","$600 ","$2,500 ","$60 ","$1,100 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Exp Bronze 6000 - no deductible for PCP visits ","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010053,"Select Health SAHA Silver 3000",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010053-01,"Standard Silver On Exchange Plan",,0.701960823,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$400 ","$4,200 ","$60 ","$1,100 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 3000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010053,"Select Health SAHA Silver 3000",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010053-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SAHA Silver 3000","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010053,"Select Health SAHA Silver 3000",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010053-03,"Limited Cost Sharing Plan Variation",,0.701960823,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$400 ","$4,200 ","$60 ","$1,100 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 3000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010053,"Select Health SAHA Silver 3000",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010053-04,"73% AV Level Silver Plan",,0.737329991,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,100 ","$7100 per person | $14200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,100 ","$1100 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$400 ","$3,400 ","$60 ","$800 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 3000","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010053,"Select Health SAHA Silver 3000",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010053-05,"87% AV Level Silver Plan",,0.871821489,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,600 ","$2600 per person | $5200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$200 ","$200 per person | per group not applicable",,,,,,,,,,,"$500 ","$300 ","$1,800 ","$60 ","$500 ","$400 ","$90 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 3000","$500 ","$900 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010053,"Select Health SAHA Silver 3000",26002ID001,,IDN003,IDS003,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010053-06,"94% AV Level Silver Plan",,0.948241329,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,200 ","$1200 per person | $2400 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$200 ","$1,000 ","$60 ","$0 ","$100 ","$200 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 3000","$0 ","$500 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010054,"Select Health SAHA Silver 4500  - no deductible for office visits",26002ID001,,IDN003,IDS003,IDF012,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010054-01,"Standard Silver On Exchange Plan",,0.718666721,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$700 ","$0 ","$60 ","$800 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 4500  - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010054,"Select Health SAHA Silver 4500  - no deductible for office visits",26002ID001,,IDN003,IDS003,IDF012,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010054-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SAHA Silver 4500  - no deductible for office visits","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010054,"Select Health SAHA Silver 4500  - no deductible for office visits",26002ID001,,IDN003,IDS003,IDF012,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010054-03,"Limited Cost Sharing Plan Variation",,0.718666721,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$700 ","$0 ","$60 ","$800 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 4500  - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010054,"Select Health SAHA Silver 4500  - no deductible for office visits",26002ID001,,IDN003,IDS003,IDF012,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010054-04,"73% AV Level Silver Plan",,0.739651212,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$700 ","$0 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 4500  - no deductible for office visits","$2,100 ","$300 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010054,"Select Health SAHA Silver 4500  - no deductible for office visits",26002ID001,,IDN003,IDS003,IDF012,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010054-05,"87% AV Level Silver Plan",,0.879599364,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,150 ","$3150 per person | $6300 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$1,100 ","$1100 per person | $2200 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$1,100 ","$1,300 ","$400 ","$60 ","$800 ","$200 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 4500  - no deductible for office visits","$1,100 ","$900 ","$90 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010054,"Select Health SAHA Silver 4500  - no deductible for office visits",26002ID001,,IDN003,IDS003,IDF012,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010054-06,"94% AV Level Silver Plan",,0.947926542,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$500 ","$300 ","$60 ","$0 ","$30 ","$200 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver 4500  - no deductible for office visits","$0 ","$900 ","$60 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010055,"Select Health SAHA Silver Copay Plan",26002ID001,,IDN003,IDS003,IDF013,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010055-01,"Standard Silver On Exchange Plan",,0.710768569,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | per group not applicable",,,,,,,,,,,"$0 ","$3,600 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver Copay Plan","$0 ","$1,700 ","$100 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010055,"Select Health SAHA Silver Copay Plan",26002ID001,,IDN003,IDS003,IDF013,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010055-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health SAHA Silver Copay Plan","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010055,"Select Health SAHA Silver Copay Plan",26002ID001,,IDN003,IDS003,IDF013,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010055-03,"Limited Cost Sharing Plan Variation",,0.710768569,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | per group not applicable",,,,,,,,,,,"$0 ","$3,600 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver Copay Plan","$0 ","$1,700 ","$100 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010055,"Select Health SAHA Silver Copay Plan",26002ID001,,IDN003,IDS003,IDF013,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010055-04,"73% AV Level Silver Plan",,0.73950388,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | per group not applicable",,,,,,,,,,,"$0 ","$3,500 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver Copay Plan","$0 ","$1,700 ","$100 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010055,"Select Health SAHA Silver Copay Plan",26002ID001,,IDN003,IDS003,IDF013,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010055-05,"87% AV Level Silver Plan",,0.878049635,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,000 ","$3000 per person | $6000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$700 ","$700 per person | per group not applicable",,,,,,,,,,,"$0 ","$1,900 ","$0 ","$60 ","$0 ","$1,100 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver Copay Plan","$0 ","$1,300 ","$70 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010055,"Select Health SAHA Silver Copay Plan",26002ID001,,IDN003,IDS003,IDF013,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010055-06,"94% AV Level Silver Plan",,0.94360662,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",10.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",10.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$1,000 ","$0 ","$60 ","$0 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health SAHA Silver Copay Plan","$0 ","$700 ","$20 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010056,"Select Health Med Gold 1000 - no deductible for office visits",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010056-01,"Standard Gold On Exchange Plan",,0.790630058,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | $2000 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$1,000 ","$10 ","$2,100 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Gold 1000 - no deductible for office visits","$1,000 ","$1,000 ","$80 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010056,"Select Health Med Gold 1000 - no deductible for office visits",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010056-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health Med Gold 1000 - no deductible for office visits","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010056,"Select Health Med Gold 1000 - no deductible for office visits",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010056-03,"Limited Cost Sharing Plan Variation",,0.790630058,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | $2000 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$1,000 ","$10 ","$2,100 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Gold 1000 - no deductible for office visits","$1,000 ","$1,000 ","$80 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010057,"Select Health Med Silver 3000",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010057-01,"Standard Silver On Exchange Plan",,0.701960823,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$400 ","$4,200 ","$60 ","$1,100 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 3000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010057,"Select Health Med Silver 3000",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010057-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health Med Silver 3000","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010057,"Select Health Med Silver 3000",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010057-03,"Limited Cost Sharing Plan Variation",,0.701960823,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$400 ","$4,200 ","$60 ","$1,100 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 3000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010057,"Select Health Med Silver 3000",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010057-04,"73% AV Level Silver Plan",,0.737329991,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,100 ","$7100 per person | $14200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,100 ","$1100 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$400 ","$3,400 ","$60 ","$800 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 3000","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010057,"Select Health Med Silver 3000",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010057-05,"87% AV Level Silver Plan",,0.871821489,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,600 ","$2600 per person | $5200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$200 ","$200 per person | per group not applicable",,,,,,,,,,,"$500 ","$300 ","$1,800 ","$60 ","$500 ","$400 ","$90 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 3000","$500 ","$900 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010057,"Select Health Med Silver 3000",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010057-06,"94% AV Level Silver Plan",,0.948241329,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,200 ","$1200 per person | $2400 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$200 ","$1,000 ","$60 ","$0 ","$100 ","$200 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 3000","$0 ","$500 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010059,"Select Health Med Silver 4000 - $0 Copay for PCP visits ",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010059-01,"Standard Silver On Exchange Plan",,0.708801775,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,000 ","$4000 per person | $8000 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$4,000 ","$600 ","$3,000 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 4000 - $0 Copay for PCP visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010059,"Select Health Med Silver 4000 - $0 Copay for PCP visits ",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010059-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health Med Silver 4000 - $0 Copay for PCP visits ","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010059,"Select Health Med Silver 4000 - $0 Copay for PCP visits ",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010059-03,"Limited Cost Sharing Plan Variation",,0.708801775,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,000 ","$4000 per person | $8000 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | per group not applicable",,,,,,,,,,,"$4,000 ","$600 ","$3,000 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 4000 - $0 Copay for PCP visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010059,"Select Health Med Silver 4000 - $0 Copay for PCP visits ",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010059-04,"73% AV Level Silver Plan",,0.732483378,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$3,600 ","$3600 per person | $7200 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,400 ","$1400 per person | per group not applicable",,,,,,,,,,,"$3,600 ","$600 ","$3,100 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 4000 - $0 Copay for PCP visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010059,"Select Health Med Silver 4000 - $0 Copay for PCP visits ",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010059-05,"87% AV Level Silver Plan",,0.874462146,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,000 ","$3000 per person | $6000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$700 ","$700 per person | $1400 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$700 ","$300 ","$2,000 ","$60 ","$700 ","$400 ","$30 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 4000 - $0 Copay for PCP visits ","$700 ","$900 ","$200 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010059,"Select Health Med Silver 4000 - $0 Copay for PCP visits ",26002ID001,,IDN004,IDS004,IDF008,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010059-06,"94% AV Level Silver Plan",,0.949404697,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,800 ","$1800 per person | $3600 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$1,800 ","$60 ","$0 ","$30 ","$200 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 4000 - $0 Copay for PCP visits ","$0 ","$500 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010060,"Select Health Med Silver 4500 - no deductible for office visits",26002ID001,,IDN004,IDS004,IDF012,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010060-01,"Standard Silver On Exchange Plan",,0.718666721,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$700 ","$0 ","$60 ","$800 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 4500 - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010060,"Select Health Med Silver 4500 - no deductible for office visits",26002ID001,,IDN004,IDS004,IDF012,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010060-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health Med Silver 4500 - no deductible for office visits","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010060,"Select Health Med Silver 4500 - no deductible for office visits",26002ID001,,IDN004,IDS004,IDF012,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010060-03,"Limited Cost Sharing Plan Variation",,0.718666721,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$700 ","$0 ","$60 ","$800 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 4500 - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010060,"Select Health Med Silver 4500 - no deductible for office visits",26002ID001,,IDN004,IDS004,IDF012,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010060-04,"73% AV Level Silver Plan",,0.739651212,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$700 ","$0 ","$60 ","$800 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 4500 - no deductible for office visits","$2,100 ","$300 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010060,"Select Health Med Silver 4500 - no deductible for office visits",26002ID001,,IDN004,IDS004,IDF012,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010060-05,"87% AV Level Silver Plan",,0.879599364,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,150 ","$3150 per person | $6300 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$1,100 ","$1100 per person | $2200 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$1,100 ","$1,300 ","$400 ","$60 ","$800 ","$200 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 4500 - no deductible for office visits","$1,100 ","$900 ","$90 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010060,"Select Health Med Silver 4500 - no deductible for office visits",26002ID001,,IDN004,IDS004,IDF012,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,5,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010060-06,"94% AV Level Silver Plan",,0.947926542,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$500 ","$300 ","$60 ","$0 ","$30 ","$200 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver 4500 - no deductible for office visits","$0 ","$900 ","$60 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010061,"Select Health Med Silver Copay Plan",26002ID001,,IDN004,IDS004,IDF013,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010061-01,"Standard Silver On Exchange Plan",,0.710768569,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | per group not applicable",,,,,,,,,,,"$0 ","$3,600 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver Copay Plan","$0 ","$1,700 ","$100 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010061,"Select Health Med Silver Copay Plan",26002ID001,,IDN004,IDS004,IDF013,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010061-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health Med Silver Copay Plan","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010061,"Select Health Med Silver Copay Plan",26002ID001,,IDN004,IDS004,IDF013,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010061-03,"Limited Cost Sharing Plan Variation",,0.710768569,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | per group not applicable",,,,,,,,,,,"$0 ","$3,600 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver Copay Plan","$0 ","$1,700 ","$100 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010061,"Select Health Med Silver Copay Plan",26002ID001,,IDN004,IDS004,IDF013,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010061-04,"73% AV Level Silver Plan",,0.73950388,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | per group not applicable",,,,,,,,,,,"$0 ","$3,500 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver Copay Plan","$0 ","$1,700 ","$100 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010061,"Select Health Med Silver Copay Plan",26002ID001,,IDN004,IDS004,IDF013,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010061-05,"87% AV Level Silver Plan",,0.878049635,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,000 ","$3000 per person | $6000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$700 ","$700 per person | per group not applicable",,,,,,,,,,,"$0 ","$1,900 ","$0 ","$60 ","$0 ","$1,100 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver Copay Plan","$0 ","$1,300 ","$70 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010061,"Select Health Med Silver Copay Plan",26002ID001,,IDN004,IDS004,IDF013,New,PPO,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010061-06,"94% AV Level Silver Plan",,0.94360662,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",10.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",10.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$1,000 ","$0 ","$60 ","$0 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Silver Copay Plan","$0 ","$700 ","$20 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010062,"Select Health Med Exp Bronze 4500",26002ID001,,IDN004,IDS004,IDF014,New,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010062-01,"Standard Bronze On Exchange Plan",,0.642908255,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,700 ","$1700 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$10 ","$4,000 ","$60 ","$1,200 ","$700 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Exp Bronze 4500","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010062,"Select Health Med Exp Bronze 4500",26002ID001,,IDN004,IDS004,IDF014,New,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010062-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health Med Exp Bronze 4500","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010062,"Select Health Med Exp Bronze 4500",26002ID001,,IDN004,IDS004,IDF014,New,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010062-03,"Limited Cost Sharing Plan Variation",,0.642908255,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,700 ","$1700 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$10 ","$4,000 ","$60 ","$1,200 ","$700 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Exp Bronze 4500","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010063,"Select Health Med Exp Bronze 6000 - no deductible for office visits ",26002ID001,,IDN004,IDS004,IDF014,New,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010063-01,"Standard Bronze On Exchange Plan",,0.647698034,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$6,000 ","$6000 per person | $12000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | per group not applicable",,,,,,,,,,,"$6,000 ","$600 ","$2,500 ","$60 ","$1,100 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Exp Bronze 6000 - no deductible for office visits ","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010063,"Select Health Med Exp Bronze 6000 - no deductible for office visits ",26002ID001,,IDN004,IDS004,IDF014,New,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010063-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health Med Exp Bronze 6000 - no deductible for office visits ","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010063,"Select Health Med Exp Bronze 6000 - no deductible for office visits ",26002ID001,,IDN004,IDS004,IDF014,New,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010063-03,"Limited Cost Sharing Plan Variation",,0.647698034,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable","$6,000 ","$6000 per person | $12000 per group",50.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | per group not applicable",,,,,,,,,,,"$6,000 ","$600 ","$2,500 ","$60 ","$1,100 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Exp Bronze 6000 - no deductible for office visits ","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010064,"Select Health Med Exp Bronze 8000 HSA Qualified ",26002ID001,,IDN004,IDS004,IDF010,New,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010064-01,"Standard Bronze On Exchange Plan",,0.629227715,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$8,000 ","per person not applicable | $16000 per group",0.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","$8,000 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Exp Bronze 8000 HSA Qualified ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010064,"Select Health Med Exp Bronze 8000 HSA Qualified ",26002ID001,,IDN004,IDS004,IDF010,New,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010064-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$60 ",100%,"Not Applicable",No,"Select Health Med Exp Bronze 8000 ","$0 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,Individual,No,,26002ID0010064,"Select Health Med Exp Bronze 8000 HSA Qualified ",26002ID001,,IDN004,IDS004,IDF010,New,PPO,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,,,,,26002ID0010064-03,"Limited Cost Sharing Plan Variation",,0.629227715,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$91,000 ","$91000 per person | $182000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$8,000 ","per person not applicable | $16000 per group",0.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","$8,000 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Select Health Med Exp Bronze 8000 ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030006,"Select Health SLHP Gold 500 - no deductible for office visits",26002ID003,,IDN005,IDS005,IDF001,Existing,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030006-01,"Standard Gold On Exchange Plan",,0.808886475,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1500 per group",30.00%,,,,"$1,500 ","$1500 per person | $4500 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$500 ","$10 ","$3,300 ","$60 ","$500 ","$500 ","$90 ","$20 ",,,Yes,"Select Health SLHP Gold 500 - no deductible for office visits","$500 ","$1,100 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030010,"Select Health SLHP Gold 1000 - no deductible for office visits",26002ID003,,IDN005,IDS005,IDF002,Existing,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030010-01,"Standard Gold On Exchange Plan",,0.809652622,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,700 ","$7700 per person | $15400 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | $3000 per group",20.00%,,,,"$3,000 ","$3000 per person | $9000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$1,000 ","$10 ","$2,100 ","$60 ","$800 ","$500 ","$0 ","$20 ",,,Yes,"Select Health SLHP Gold 1000 - no deductible for office visits","$1,000 ","$1,100 ","$80 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030011,"Select Health SLHP Silver 3500 - no deductible for office visits",26002ID003,,IDN005,IDS005,IDF003,Existing,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030011-01,"Standard Silver On Exchange Plan",,0.707510211,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",30.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | $600 per group",,,,,,,,,,,"$3,500 ","$10 ","$2,600 ","$60 ","$900 ","$600 ","$0 ","$20 ",,,Yes,"Select Health SLHP Silver 3500 - no deductible for office visits","$2,100 ","$500 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030012,"Select Health SLHP Gold 2000 - no deductible for office visits",26002ID003,,IDN005,IDS005,IDF002,Existing,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030012-01,"Standard Gold On Exchange Plan",,0.810921947,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,200 ","$6200 per person | $12400 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$6,000 ","$6000 per person | $12000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$2,000 ","$10 ","$1,900 ","$60 ","$800 ","$400 ","$0 ","$20 ",,,Yes,"Select Health SLHP Gold 2000 - no deductible for office visits","$2,000 ","$400 ","$20 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030014,"Select Health SLHP Silver 3000 HSA Qualified",26002ID003,,IDN001,IDS001,IDF006,Existing,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030014-01,"Standard Silver On Exchange Plan",,0.706062669,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,000 ","per person not applicable | $6000 per group",30.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$10 ","$2,600 ","$60 ","$3,000 ","$200 ","$100 ","$20 ",,,Yes,"Select Health SLHP Silver 3000 HSA Qualified","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030016,"Select Health SLHP Bronze 8000 HSA Qualified",26002ID003,,IDN005,IDS005,IDF005,Existing,POS,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030016-01,"Standard Bronze On Exchange Plan",,0.629227715,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$8,000 ","per person not applicable | $16000 per group",0.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","$8,000 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",,,Yes,"Select Health SLHP Bronze 8000 HSA Qualified","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030020,"Select Health SLHP Silver 5500 - no deductible for office visits",26002ID003,,IDN005,IDS005,IDF004,Existing,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030020-01,"Standard Silver On Exchange Plan",,0.716722007,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,500 ","$8500 per person | $17000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | $600 per group",,,,,,,,,,,"$5,500 ","$400 ","$1,800 ","$60 ","$800 ","$600 ","$0 ","$20 ",,,Yes,"Select Health SLHP Silver 5500 - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030021,"Select Health SLHP Bronze 9000 - no deductible for office visits",26002ID003,,IDN005,IDS005,IDF005,Existing,POS,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030021-01,"Standard Bronze On Exchange Plan",,0.649750945,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$18,400 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",0.00%,,,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable","$9,000 ","$0 ","$0 ","$60 ","$4,400 ","$500 ","$0 ","$20 ",,,Yes,"Select Health SLHP Bronze 9000 - no deductible for office visits","$2,100 ","$500 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030023,"Select Health SLHP Gold 3000 - no deductible for office visits",26002ID003,,IDN005,IDS005,IDF002,Existing,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030023-01,"Standard Gold On Exchange Plan",,0.810013028,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,500 ","$5500 per person | $11000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$3,000 ","$10 ","$1,700 ","$60 ","$800 ","$400 ","$0 ","$20 ",,,Yes,"Select Health SLHP Gold 3000 - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030024,"Select Health SLHP Silver 4500 - no deductible for office visits ",26002ID003,,IDN005,IDS005,IDF003,Existing,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030024-01,"Standard Silver On Exchange Plan",,0.704854682,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$8,000 ","$8000 per person | $16000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | $600 per group",,,,,,,,,,,"$4,500 ","$10 ","$2,400 ","$60 ","$900 ","$600 ","$0 ","$20 ",,,Yes,"Select Health SLHP Silver 4500 - no deductible for office visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030025,"Select Health SLHP Silver 5500 HSA Qualified",26002ID003,,IDN005,IDS005,IDF005,Existing,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030025-01,"Standard Silver On Exchange Plan",,0.707495906,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,500 ","$5500 per person | $11000 per group",,,"$16,500 ","$16500 per person | $33000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,500 ","per person not applicable | $11000 per group",0.00%,,,,"$16,500 ","$16500 per person | $33000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",,,Yes,"Select Health SLHP Silver 5500 HSA Qualified","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030026,"Select Health SLHP Gold Copay Plan",26002ID003,,IDN005,IDS005,IDF007,Existing,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030026-01,"Standard Gold On Exchange Plan",,0.806237812,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$3,000 ","$3000 per person | $9000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$0 ","$1,500 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",,,Yes,"Select Health SLHP Gold Copay Plan","$0 ","$1,700 ","$70 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030028,"BrightPath Gold 500 - no deductible for office visits",26002ID003,,IDN006,IDS006,IDF001,Existing,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030028-01,"Standard Gold On Exchange Plan",,0.808886475,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1500 per group",30.00%,,,,"$1,500 ","$1500 per person | $4500 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$500 ","$10 ","$3,300 ","$60 ","$500 ","$500 ","$90 ","$20 ",,,Yes,"BrightPath Gold 500 - no deductible for office visits","$500 ","$1,100 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030029,"BrightPath Gold 1000 - no deductible for office visits",26002ID003,,IDN006,IDS006,IDF002,Existing,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030029-01,"Standard Gold On Exchange Plan",,0.809652622,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,700 ","$7700 per person | $15400 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | $3000 per group",20.00%,,,,"$3,000 ","$3000 per person | $9000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$1,000 ","$10 ","$2,100 ","$60 ","$800 ","$500 ","$0 ","$20 ",,,Yes,"BrightPath Gold 1000 - no deductible for office visits","$1,000 ","$1,100 ","$80 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030031,"BrightPath Gold 2000 - no deductible for office visits",26002ID003,,IDN006,IDS006,IDF002,Existing,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030031-01,"Standard Gold On Exchange Plan",,0.810921947,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,200 ","$6200 per person | $12400 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$6,000 ","$6000 per person | $12000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$2,000 ","$10 ","$1,900 ","$60 ","$800 ","$400 ","$0 ","$20 ",,,Yes,"BrightPath Gold 2000 - no deductible for office visits","$2,000 ","$400 ","$20 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030032,"BrightPath Gold 3000 - no deductible for office visits and Rx",26002ID003,,IDN006,IDS006,IDF002,Existing,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030032-01,"Standard Gold On Exchange Plan",,0.810013028,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,500 ","$5500 per person | $11000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$3,000 ","$10 ","$1,700 ","$60 ","$800 ","$400 ","$0 ","$20 ",,,Yes,"BrightPath Gold 3000 - no deductible for office visits and Rx","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030033,"BrightPath Silver 3500 - no deductible for office visits",26002ID003,,IDN006,IDS006,IDF003,Existing,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030033-01,"Standard Silver On Exchange Plan",,0.707510211,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",30.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | $600 per group",,,,,,,,,,,"$3,500 ","$10 ","$2,600 ","$60 ","$900 ","$600 ","$0 ","$20 ",,,Yes,"BrightPath Silver 3500 - no deductible for office visits","$2,100 ","$500 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030034,"BrightPath Silver 4500 - no deductible for office visits ",26002ID003,,IDN006,IDS006,IDF003,Existing,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030034-01,"Standard Silver On Exchange Plan",,0.704854682,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$8,000 ","$8000 per person | $16000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | $600 per group",,,,,,,,,,,"$4,500 ","$10 ","$2,400 ","$60 ","$900 ","$600 ","$0 ","$20 ",,,Yes,"BrightPath Silver 4500 - no deductible for office visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030035,"BrightPath Silver 5500 - no deductible for office visits",26002ID003,,IDN006,IDS006,IDF004,Existing,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030035-01,"Standard Silver On Exchange Plan",,0.716722007,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,500 ","$8500 per person | $17000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | $600 per group",,,,,,,,,,,"$5,500 ","$400 ","$1,800 ","$60 ","$800 ","$600 ","$0 ","$20 ",,,Yes,"BrightPath Silver 5500 - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030037,"BrightPath Bronze 9000 - no deductible for office visits",26002ID003,,IDN006,IDS006,IDF005,Existing,POS,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030037-01,"Standard Bronze On Exchange Plan",,0.649750945,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$18,400 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",0.00%,,,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable","$9,000 ","$0 ","$0 ","$60 ","$4,400 ","$500 ","$0 ","$20 ",,,Yes,"BrightPath Bronze 9000 - no deductible for office visits","$2,100 ","$500 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030038,"BrightPath Silver 3000 HSA Qualified",26002ID003,,IDN006,IDS006,IDF006,Existing,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030038-01,"Standard Silver On Exchange Plan",,0.706062669,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,000 ","per person not applicable | $6000 per group",30.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$10 ","$2,600 ","$60 ","$3,000 ","$200 ","$100 ","$20 ",,,Yes,"BrightPath Silver 3000 HSA Qualified","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030039,"BrightPath Silver 5500 HSA Qualified",26002ID003,,IDN006,IDS006,IDF005,Existing,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030039-01,"Standard Silver On Exchange Plan",,0.707495906,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,500 ","$5500 per person | $11000 per group",,,"$16,500 ","$16500 per person | $33000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,500 ","per person not applicable | $11000 per group",0.00%,,,,"$16,500 ","$16500 per person | $33000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",,,Yes,"BrightPath Silver 5500 HSA Qualified","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030040,"BrightPath Bronze 8000 HSA Qualified",26002ID003,,IDN006,IDS006,IDF005,Existing,POS,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030040-01,"Standard Bronze On Exchange Plan",,0.629227715,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$8,000 ","per person not applicable | $16000 per group",0.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","$8,000 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",,,Yes,"BrightPath Bronze 8000 HSA Qualified","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030041,"BrightPath Gold Copay Plan",26002ID003,,IDN006,IDS006,IDF007,Existing,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030041-01,"Standard Gold On Exchange Plan",,0.806237812,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$3,000 ","$3000 per person | $9000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$0 ","$1,500 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",,,Yes,"BrightPath Gold Copay Plan","$0 ","$1,700 ","$70 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030043,"Select Health Med Gold 500 - no deductible for office visits",26002ID003,,IDN008,IDS008,IDF001,New,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030043-01,"Standard Gold On Exchange Plan",,0.808886475,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1500 per group",30.00%,,,,"$1,500 ","$1500 per person | $4500 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$500 ","$10 ","$3,300 ","$60 ","$500 ","$500 ","$90 ","$20 ",,,Yes,"Select Health Med Gold 500 - no deductible for office visits","$500 ","$1,100 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030044,"Select Health Med Gold 1000 - no deductible for office visits",26002ID003,,IDN008,IDS008,IDF002,New,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030044-01,"Standard Gold On Exchange Plan",,0.809652622,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,700 ","$7700 per person | $15400 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | $3000 per group",20.00%,,,,"$3,000 ","$3000 per person | $9000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$1,000 ","$10 ","$2,100 ","$60 ","$800 ","$500 ","$0 ","$20 ",,,Yes,"Select Health Med Gold 1000 - no deductible for office visits","$1,000 ","$1,100 ","$80 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030046,"Select Health Med Gold 2000 - no deductible for office visits",26002ID003,,IDN008,IDS008,IDF002,New,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030046-01,"Standard Gold On Exchange Plan",,0.810921947,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,200 ","$6200 per person | $12400 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$6,000 ","$6000 per person | $12000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$2,000 ","$10 ","$1,900 ","$60 ","$800 ","$400 ","$0 ","$20 ",,,Yes,"Select Health Med Gold 2000 - no deductible for office visits","$2,000 ","$400 ","$20 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030047,"Select Health Med Gold 3000 - no deductible for office visits",26002ID003,,IDN008,IDS008,IDF002,New,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030047-01,"Standard Gold On Exchange Plan",,0.810013028,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,500 ","$5500 per person | $11000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$3,000 ","$10 ","$1,700 ","$60 ","$800 ","$400 ","$0 ","$20 ",,,Yes,"Select Health Med Gold 3000 - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030048,"Select Health Med Gold Copay Plan",26002ID003,,IDN008,IDS008,IDF007,New,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030048-01,"Standard Gold On Exchange Plan",,0.806237812,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$3,000 ","$3000 per person | $9000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$0 ","$1,500 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",,,Yes,"Select Health Med Gold Copay Plan","$0 ","$1,700 ","$70 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030049,"Select Health Med Silver 3500 - no deductible for office visits",26002ID003,,IDN008,IDS008,IDF003,New,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030049-01,"Standard Silver On Exchange Plan",,0.707510211,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",30.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | $600 per group",,,,,,,,,,,"$3,500 ","$10 ","$2,600 ","$60 ","$900 ","$600 ","$0 ","$20 ",,,Yes,"Select Health Med Silver 3500 - no deductible for office visits","$2,100 ","$500 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030050,"Select Health Med Silver 4500 - no deductible for office visits ",26002ID003,,IDN008,IDS008,IDF003,New,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030050-01,"Standard Silver On Exchange Plan",,0.704854682,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$8,000 ","$8000 per person | $16000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | $600 per group",,,,,,,,,,,"$4,500 ","$10 ","$2,400 ","$60 ","$900 ","$600 ","$0 ","$20 ",,,Yes,"Select Health Med Silver 4500 - no deductible for office visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030051,"Select Health Med Silver 5500 - no deductible for office visits",26002ID003,,IDN008,IDS008,IDF004,New,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030051-01,"Standard Silver On Exchange Plan",,0.716722007,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,500 ","$8500 per person | $17000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | $600 per group",,,,,,,,,,,"$5,500 ","$400 ","$1,800 ","$60 ","$800 ","$600 ","$0 ","$20 ",,,Yes,"Select Health Med Silver 5500 - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030052,"Select Health Med Silver 3000 HSA Qualified",26002ID003,,IDN008,IDS008,IDF006,New,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030052-01,"Standard Silver On Exchange Plan",,0.706062669,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,000 ","per person not applicable | $6000 per group",30.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$10 ","$2,600 ","$60 ","$3,000 ","$200 ","$100 ","$20 ",,,Yes,"Select Health Med Silver 3000 HSA Qualified","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030053,"Select Health Med Silver 5500 HSA Qualified",26002ID003,,IDN008,IDS008,IDF005,New,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030053-01,"Standard Silver On Exchange Plan",,0.707495906,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,500 ","$5500 per person | $11000 per group",,,"$16,500 ","$16500 per person | $33000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,500 ","per person not applicable | $11000 per group",0.00%,,,,"$16,500 ","$16500 per person | $33000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",,,Yes,"Select Health Med Silver 5500 HSA Qualified","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030054,"Select Health Med Bronze 9000 - no deductible for office visits",26002ID003,,IDN008,IDS008,IDF005,New,POS,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030054-01,"Standard Bronze On Exchange Plan",,0.649750945,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$18,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",0.00%,,,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable","$9,000 ","$0 ","$0 ","$60 ","$4,400 ","$500 ","$0 ","$20 ",,,Yes,"Select Health Med Bronze 9000 - no deductible for office visits","$2,100 ","$500 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030055,"Select Health Med Bronze 8000 HSA Qualified",26002ID003,,IDN008,IDS008,IDF005,New,POS,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030055-01,"Standard Bronze On Exchange Plan",,0.629227715,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$8,000 ","per person not applicable | $16000 per group",0.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","$8,000 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",,,Yes,"Select Health Med Bronze 8000 HSA Qualified","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030056,"Select Health SAHA Gold 500 - no deductible for office visits",26002ID003,,IDN007,IDS007,IDF001,New,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030056-01,"Standard Gold On Exchange Plan",,0.808886475,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1500 per group",30.00%,,,,"$1,500 ","$1500 per person | $4500 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$500 ","$10 ","$3,300 ","$60 ","$500 ","$500 ","$90 ","$20 ",,,Yes,"Select Health SAHA Gold 500 - no deductible for office visits","$500 ","$1,100 ","$300 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030057,"Select Health SAHA Gold 1000 - no deductible for office visits",26002ID003,,IDN007,IDS007,IDF002,New,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030057-01,"Standard Gold On Exchange Plan",,0.809652622,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,700 ","$7700 per person | $15400 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | $3000 per group",20.00%,,,,"$3,000 ","$3000 per person | $9000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$1,000 ","$10 ","$2,100 ","$60 ","$800 ","$500 ","$0 ","$20 ",,,Yes,"Select Health SAHA Gold 1000 - no deductible for office visits","$1,000 ","$1,100 ","$80 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030059,"Select Health SAHA Gold 2000 - no deductible for office visits",26002ID003,,IDN007,IDS007,IDF002,New,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030059-01,"Standard Gold On Exchange Plan",,0.810921947,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,200 ","$6200 per person | $12400 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$6,000 ","$6000 per person | $12000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$2,000 ","$10 ","$1,900 ","$60 ","$800 ","$400 ","$0 ","$20 ",,,Yes,"Select Health SAHA Gold 2000 - no deductible for office visits","$2,000 ","$400 ","$20 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030060,"SelectHealth SAHA Gold 3000 - no deductible for office visits",26002ID003,,IDN007,IDS007,IDF002,New,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030060-01,"Standard Gold On Exchange Plan",,0.810013028,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,500 ","$5500 per person | $11000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",25.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,"$3,000 ","$10 ","$1,700 ","$60 ","$800 ","$400 ","$0 ","$20 ",,,Yes,"Select Health SAHA Gold 3000 - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030061,"Select Health SAHA Gold Copay Plan",26002ID003,,IDN007,IDS007,IDF007,New,POS,Gold,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,3,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030061-01,"Standard Gold On Exchange Plan",,0.806237812,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$3,000 ","$3000 per person | $9000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$0 ","$1,500 ","$0 ","$60 ","$0 ","$1,300 ","$0 ","$20 ",,,Yes,"Select Health SAHA Gold Copay Plan","$0 ","$1,700 ","$70 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030062,"Select Health SAHA Silver 3500 - no deductible for office visits",26002ID003,,IDN007,IDS007,IDF003,New,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030062-01,"Standard Silver On Exchange Plan",,0.707510211,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",30.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | $600 per group",,,,,,,,,,,"$3,500 ","$10 ","$2,600 ","$60 ","$900 ","$600 ","$0 ","$20 ",,,Yes,"Select Health SAHA Silver 3500 - no deductible for office visits","$2,100 ","$500 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030063,"Select Health SAHA Silver 4500 - no deductible for office visits ",26002ID003,,IDN007,IDS007,IDF003,New,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030063-01,"Standard Silver On Exchange Plan",,0.704854682,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$8,000 ","$8000 per person | $16000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | $600 per group",,,,,,,,,,,"$4,500 ","$10 ","$2,400 ","$60 ","$900 ","$600 ","$0 ","$20 ",,,Yes,"Select Health SAHA Silver 4500 - no deductible for office visits ","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030064,"Select Health SAHA Silver 5500 - no deductible for office visits",26002ID003,,IDN007,IDS007,IDF004,New,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030064-01,"Standard Silver On Exchange Plan",,0.716722007,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,500 ","$8500 per person | $17000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | $600 per group",,,,,,,,,,,"$5,500 ","$400 ","$1,800 ","$60 ","$800 ","$600 ","$0 ","$20 ",,,Yes,"Select Health SAHA Silver 5500 - no deductible for office visits","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030065,"Select Health SAHA Silver 3000 HSA Qualified",26002ID003,,IDN007,IDS007,IDF006,New,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030065-01,"Standard Silver On Exchange Plan",,0.706062669,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,000 ","per person not applicable | $6000 per group",30.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$10 ","$2,600 ","$60 ","$3,000 ","$200 ","$100 ","$20 ",,,Yes,"Select Health SAHA Silver 3000 HSA Qualified","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030066,"Select Health SAHA Silver 5500 HSA Qualified",26002ID003,,IDN007,IDS007,IDF005,New,POS,Silver,No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030066-01,"Standard Silver On Exchange Plan",,0.707495906,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,500 ","$5500 per person | $11000 per group",,,"$16,500 ","$16500 per person | $33000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,500 ","per person not applicable | $11000 per group",0.00%,,,,"$16,500 ","$16500 per person | $33000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",,,Yes,"Select Health SAHA Silver 5500 HSA Qualified","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030067,"Select Health SAHA Bronze 9000 - no deductible for office visits",26002ID003,,IDN007,IDS007,IDF005,New,POS,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030067-01,"Standard Bronze On Exchange Plan",,0.649750945,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$18,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",0.00%,,,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable","$9,000 ","$0 ","$0 ","$60 ","$4,400 ","$500 ","$0 ","$20 ",,,Yes,"Select Health SAHA Bronze 9000 - no deductible for office visits","$2,100 ","$500 ","$0 ","$0 "
2024,ID,,26002,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,26002ID0030068,"Select Health SAHA Bronze 8000 HSA Qualified",26002ID003,,IDN007,IDS007,IDF005,New,POS,"Expanded Bronze",No,Both,No,No,,"Abortions/Termination of Pregnancy (except to save the life of the mother or when caused by rape/incest); Acupuncture/Acupressure; Administrative Services/Charges; Certain Allergy Tests; Bariatric Surgery; Biofeedback/Neurofeedback; Certain Cancer Therapies; Certain Illegal Activities; Claims After One Year; Complementary/Alternative Medicine; Complications of a Non-Covered Service; Custodial Care; Debarred Providers; Dental Anesthesia where criteria is not met; Duplication of Coverage; Exercise Equipment/Fitness Training; Experimental/Investigational Services (except for approved clinical trials); Refractive Eye Surgery; Food Supplements; Gene Therapy; Hearing Aids where criteria is not met; Home Health Aides; Certain Immunizations; Certain Pain Management Services; Certain Prescription/Injectable Drugs and Specialty Medications; Reconstructive, Corrective, and Cosmetic Services; Respite Care; Robot-Assisted Surgery; Sexual Dysfunction; Certain Specialty Services; Travel-Related Expenses;  computer-assisted interpretation of X-rays; Computer-assisted navigation for orthopedic procedures; Home A1C testing; Magnetic Source Imaging (MSI); Manipulation under anesthesia; Oncofertility; Radiofrequency ablation for lateral epicondylitis; Virtual colonoscopy screening; and certain DME items.",Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,No,"All covered services obtained outside of the service area, except urgent, or emergency conditions, apply to nonparticipating benefits",Yes,"Except for urgent and emergency care, out-of-network benefits apply to providers not in the network listed in your plan materials",Yes,,,,,26002ID0030068-01,"Standard Bronze On Exchange Plan",,0.629227715,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$8,000 ","per person not applicable | $16000 per group",0.00%,,,,"$18,200 ","$18200 per person | $36400 per group","Not Applicable","per person not applicable | per group not applicable","$8,000 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",,,Yes,"Select Health SAHA Bronze 8000 HSA Qualified","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100002,"LINK GOLD",38128ID010,,IDN001,IDS001,IDF001,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100002-01,"Standard Gold On Exchange Plan",,0.816068255,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",,,"$14,000 ","$14000 per person | $28000 per group","$21,000 ","$21000 per person | $42000 per group",,,,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",30.00%,,,,"$2,000 ","$2000 per person | $4000 per group","$3,000 ","$3000 per person | $6000 per group","$900 ","$10 ","$3,600 ","$60 ","$900 ","$300 ","$0 ","$20 ",100%,"Not Applicable",Yes,"LINK GOLD","$1,000 ","$200 ","$500 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100002,"LINK GOLD",38128ID010,,IDN001,IDS001,IDF001,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100002-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",Yes,"LINK GOLD","$0 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100002,"LINK GOLD",38128ID010,,IDN001,IDS001,IDF001,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100002-03,"Limited Cost Sharing Plan Variation",,0.816068255,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",,,"$14,000 ","$14000 per person | $28000 per group","$21,000 ","$21000 per person | $42000 per group",,,,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",30.00%,,,,"$2,000 ","$2000 per person | $4000 per group","$3,000 ","$3000 per person | $6000 per group","$900 ","$10 ","$3,600 ","$60 ","$900 ","$300 ","$0 ","$20 ",100%,"Not Applicable",Yes,"LINK GOLD","$1,000 ","$200 ","$500 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100003,"LINK  SILVER ",38128ID010,,IDN001,IDS001,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100003-01,"Standard Silver On Exchange Plan",,0.719354033,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,150 ","$8150 per person | $16300 per group",,,"$24,450 ","$24450 per person | $48900 per group","$32,600 ","$32600 per person | $65200 per group",,,,,,,,,,,,,,,,,,,,,"$6,000 ","$6000 per person | $12000 per group",30.00%,,,,"$17,100 ","$17100 per person | $34200 per group","$23,100 ","$23100 per person | $46200 per group","$6,000 ","$10 ","$2,000 ","$60 ","$900 ","$400 ","$0 ","$20 ",100%,"Not Applicable",Yes,"LINK  SILVER ","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100003,"LINK  SILVER ",38128ID010,,IDN001,IDS001,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100003-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",Yes,"LINK  SILVER ","$0 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100003,"LINK  SILVER ",38128ID010,,IDN001,IDS001,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100003-03,"Limited Cost Sharing Plan Variation",,0.719354033,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,150 ","$8150 per person | $16300 per group",,,"$24,450 ","$24450 per person | $48900 per group","$32,600 ","$32600 per person | $65200 per group",,,,,,,,,,,,,,,,,,,,,"$6,000 ","$6000 per person | $12000 per group",30.00%,,,,"$17,100 ","$17100 per person | $34200 per group","$23,100 ","$23100 per person | $46200 per group","$6,000 ","$10 ","$2,000 ","$60 ","$900 ","$400 ","$0 ","$20 ",100%,"Not Applicable",Yes,"LINK  SILVER ","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100003,"LINK  SILVER ",38128ID010,,IDN001,IDS001,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100003-04,"73% AV Level Silver Plan",,0.73966519,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,900 ","$6900 per person | $13800 per group",,,"$19,800 ","$19800 per person | $39600 per group","$26,700 ","$26700 per person | $53400 per group",,,,,,,,,,,,,,,,,,,,,"$5,000 ","$5000 per person | $10000 per group",30.00%,,,,"$13,500 ","$13500 per person | $27000 per group","$18,500 ","$18500 per person | $37000 per group","$5,000 ","$0 ","$1,900 ","$60 ","$900 ","$400 ","$0 ","$20 ",100%,"Not Applicable",Yes,"LINK  SILVER ","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100003,"LINK  SILVER ",38128ID010,,IDN001,IDS001,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100003-05,"87% AV Level Silver Plan",,0.879128225,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,800 ","$2800 per person | $5600 per group",,,"$8,400 ","$8400 per person | $16800 per group","$11,200 ","$11200 per person | $22400 per group",,,,,,,,,,,,,,,,,,,,,"$600 ","$600 per person | $1200 per group",30.00%,,,,"$1,800 ","$1800 per person | $3600 per group","$2,400 ","$2400 per person | $4800 per group","$600 ","$0 ","$2,200 ","$60 ","$600 ","$300 ","$90 ","$20 ",100%,"Not Applicable",Yes,"LINK  SILVER ","$600 ","$100 ","$700 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100003,"LINK  SILVER ",38128ID010,,IDN001,IDS001,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100003-06,"94% AV Level Silver Plan",,0.949743025,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",,,"$3,000 ","$3000 per person | $6000 per group","$4,000 ","$4000 per person | $8000 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",20.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$1,000 ","$60 ","$0 ","$50 ","$200 ","$20 ",100%,"Not Applicable",Yes,"LINK  SILVER ","$0 ","$80 ","$700 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100004,"LINK BRONZE ",38128ID010,,IDN001,IDS001,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100004-01,"Standard Bronze On Exchange Plan",,0.649870744,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$25,000 ","$25000 per person | $50000 per group","$33,900 ","$33900 per person | $67800 per group",,,,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",0.00%,,,,"$25,000 ","$25000 per person | $50000 per group","$33,900 ","$33900 per person | $67800 per group","$8,900 ","$0 ","$0 ","$60 ","$4,700 ","$0 ","$0 ","$20 ",100%,"Not Applicable",Yes,"LINK BRONZE ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100004,"LINK BRONZE ",38128ID010,,IDN001,IDS001,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100004-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",Yes,"LINK BRONZE ","$0 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100004,"LINK BRONZE ",38128ID010,,IDN001,IDS001,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100004-03,"Limited Cost Sharing Plan Variation",,0.649870744,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$25,000 ","$25000 per person | $50000 per group","$33,900 ","$33900 per person | $67800 per group",,,,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",0.00%,,,,"$25,000 ","$25000 per person | $50000 per group","$33,900 ","$33900 per person | $67800 per group","$8,900 ","$0 ","$0 ","$60 ","$4,700 ","$0 ","$0 ","$20 ",100%,"Not Applicable",Yes,"LINK BRONZE ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100007,"LINK  BRONZE HDHP ",38128ID010,,IDN001,IDS001,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,Yes,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100007-01,"Standard Bronze On Exchange Plan",,0.639604829,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group","$7,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",Yes,"LINK  BRONZE HDHP ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100007,"LINK  BRONZE HDHP ",38128ID010,,IDN001,IDS001,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100007-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",Yes,"LINK  BRONZE HD","$0 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100007,"LINK  BRONZE HDHP ",38128ID010,,IDN001,IDS001,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100007-03,"Limited Cost Sharing Plan Variation",,0.639604829,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group","$7,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",Yes,"LINK  BRONZE HD","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100009,"LINK SILVER  OPTION 2",38128ID010,,IDN001,IDS001,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100009-01,"Standard Silver On Exchange Plan",,0.717542626,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$24,000 ","$24000 per person | $48000 per group","$33,000 ","$33000 per person | $66000 per group",,,,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",40.00%,,,,"$19,500 ","$19500 per person | $39000 per group","$27,500 ","$27500 per person | $55000 per group","$8,000 ","$0 ","$1,000 ","$60 ","$900 ","$400 ","$0 ","$20 ",100%,"Not Applicable",Yes,"LINK SILVER  OPTION 2","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100009,"LINK SILVER  OPTION 2",38128ID010,,IDN001,IDS001,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100009-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",Yes,"LINK SILVER  OPTION 2","$0 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100009,"LINK SILVER  OPTION 2",38128ID010,,IDN001,IDS001,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100009-03,"Limited Cost Sharing Plan Variation",,0.717542626,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$24,000 ","$24000 per person | $48000 per group","$33,000 ","$33000 per person | $66000 per group",,,,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",40.00%,,,,"$19,500 ","$19500 per person | $39000 per group","$27,500 ","$27500 per person | $55000 per group","$8,000 ","$0 ","$1,000 ","$60 ","$900 ","$400 ","$0 ","$20 ",100%,"Not Applicable",Yes,"LINK SILVER  OPTION 2","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100009,"LINK SILVER  OPTION 2",38128ID010,,IDN001,IDS001,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100009-04,"73% AV Level Silver Plan",,0.738792441,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$21,000 ","$21000 per person | $42000 per group","$29,000 ","$29000 per person | $58000 per group",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$19,500 ","$19500 per person | $39000 per group","$26,500 ","$26500 per person | $53000 per group","$7,000 ","$0 ","$1,000 ","$60 ","$900 ","$300 ","$0 ","$20 ",100%,"Not Applicable",Yes,"LINK SILVER  OPTION 2","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100009,"LINK SILVER  OPTION 2",38128ID010,,IDN001,IDS001,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100009-05,"87% AV Level Silver Plan",,0.87997752,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,800 ","$2800 per person | $5600 per group",,,"$8,400 ","$8400 per person | $16800 per group","$11,200 ","$11200 per person | $22400 per group",,,,,,,,,,,,,,,,,,,,,"$800 ","$800 per person | $1600 per group",30.00%,,,,"$2,400 ","$2400 per person | $4800 per group","$3,200 ","$3200 per person | $6400 per group","$800 ","$0 ","$2,000 ","$60 ","$800 ","$90 ","$30 ","$20 ",100%,"Not Applicable",Yes,"LINK SILVER  OPTION 2","$800 ","$100 ","$600 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100009,"LINK SILVER  OPTION 2",38128ID010,,IDN001,IDS001,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100009-06,"94% AV Level Silver Plan",,0.948431235,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",,,"$2,700 ","$2700 per person | $5400 per group","$3,700 ","$3700 per person | $7400 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",20.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$1,000 ","$60 ","$0 ","$70 ","$200 ","$20 ",100%,"Not Applicable",Yes,"LINK SILVER  OPTION 2","$0 ","$100 ","$700 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100011,"LINK CATASTROPHIC ",38128ID010,,IDN001,IDS001,IDF003,Existing,POS,Catastrophic,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,3,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100011-01,"Standard Catastrophic On Exchange Plan",,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$27,300 ","$27300 per person | $54600 per group","$36,750 ","$36750 per person | $73500 per group",,,,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",0.00%,,,,"$27,300 ","$27300 per person | $54600 per group","$36,750 ","$36750 per person | $73500 per group","$9,450 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",Yes,"LINK CATASTROPHIC ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100012,"LINK PLATINUM",38128ID010,,IDN001,IDS001,IDF001,New,POS,Platinum,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100012-01,"Standard Platinum On Exchange Plan",,0.910676711,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",,,"$4,000 ","$4000 per person | $8000 per group","$5,500 ","$5500 per person | $11000 per group",,,,,,,,,,,,,,,,,,,,,"$500 ","$500 per person | $1000 per group",10.00%,,,,"$2,000 ","$2000 per person | $4000 per group","$2,500 ","$2500 per person | $5000 per group","$500 ","$0 ","$1,000 ","$60 ","$500 ","$300 ","$40 ","$20 ",100%,"Not Applicable",Yes,"LINK PLATINUM","$500 ","$100 ","$300 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100012,"LINK PLATINUM",38128ID010,,IDN001,IDS001,IDF001,New,POS,Platinum,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100012-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",Yes,"LINK PLATINUM","$0 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0100012,"LINK PLATINUM",38128ID010,,IDN001,IDS001,IDF001,New,POS,Platinum,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0100012-03,"Limited Cost Sharing Plan Variation",,0.910676711,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",,,"$4,000 ","$4000 per person | $8000 per group","$5,500 ","$5500 per person | $11000 per group",,,,,,,,,,,,,,,,,,,,,"$500 ","$500 per person | $1000 per group",10.00%,,,,"$2,000 ","$2000 per person | $4000 per group","$2,500 ","$2500 per person | $5000 per group","$500 ","$0 ","$1,000 ","$60 ","$500 ","$300 ","$40 ","$20 ",100%,"Not Applicable",Yes,"LINK PLATINUM","$500 ","$100 ","$300 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0130002,"LINK GOLD ",38128ID013,,IDN004,IDS005,IDF004,Existing,POS,Gold,No,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0130002-01,"Standard Gold On Exchange Plan",,0.816068255,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",,,"$18,000 ","$18000 per person | $36000 per group","$25,000 ","$25000 per person | $50000 per group",,,,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",30.00%,,,,"$2,250 ","$2250 per person | $4500 per group","$3,250 ","$3250 per person | $6500 per group","$1,000 ","$10 ","$3,600 ","$60 ","$900 ","$300 ","$0 ","$20 ",,,Yes,"LINK GOLD ","$1,000 ","$200 ","$500 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0130003,"LINK SILVER ",38128ID013,,IDN004,IDS005,IDF005,Existing,POS,Silver,No,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0130003-01,"Standard Silver On Exchange Plan",,0.717715447,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,150 ","$8150 per person | $16300 per group",,,"$24,450 ","$24450 per person | $48900 per group","$32,600 ","$32600 per person | $65200 per group",,,,,,,,,,,,,,,,,,,,,"$6,400 ","$6400 per person | $12800 per group",30.00%,,,,"$17,100 ","$17100 per person | $34200 per group","$23,100 ","$23100 per person | $46200 per group","$6,400 ","$0 ","$1,800 ","$60 ","$1,200 ","$300 ","$0 ","$20 ",,,Yes,"LINK SILVER ","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0130006,"LINK SILVER  HDHP",38128ID013,,IDN004,IDS005,IDF006,Existing,POS,Silver,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0130006-01,"Standard Silver On Exchange Plan",,0.701861634,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,700 ","$5700 per person | $11400 per group",,,"$15,000 ","$15000 per person | $30000 per group","$20,700 ","$20700 per person | $41400 per group",,,,,,,,,,,,,,,,,,,,,"$5,700 ","$5700 per person | $11400 per group",0.00%,,,,"$15,000 ","$15000 per person | $30000 per group","$20,700 ","$20700 per person | $41400 per group","$5,700 ","$0 ","$0 ","$60 ","$4,700 ","$0 ","$0 ","$20 ",,,Yes,"LINK SILVER  HDHP","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0130007,"LINK BRONZE  HDHP",38128ID013,,IDN004,IDS005,IDF006,Existing,POS,"Expanded Bronze",No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0130007-01,"Standard Bronze On Exchange Plan",,0.639604829,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group","$7,500 ","$0 ","$0 ","$60 ","$4,700 ","$0 ","$0 ","$20 ",,,Yes,"LINK BRONZE  HDHP","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0130008,"LINK GOLD OPTION 2",38128ID013,,IDN004,IDS005,IDF005,Existing,POS,Gold,No,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0130008-01,"Standard Gold On Exchange Plan",,0.793409533,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",,,"$13,000 ","$13000 per person | $26000 per group","$19,500 ","$19500 per person | $39000 per group",,,,,,,,,,,,,,,,,,,,,"$1,800 ","$1800 per person | $3600 per group",30.00%,,,,"$3,200 ","$3200 per person | $6400 per group","$4,800 ","$4800 per person | $9600 per group","$1,800 ","$10 ","$3,400 ","$60 ","$900 ","$400 ","$0 ","$20 ",,,Yes,"LINK GOLD OPTION 2","$1,800 ","$200 ","$200 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0130009,"LINK SILVER OPTION 2",38128ID013,,IDN004,IDS005,IDF005,Existing,POS,Silver,No,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0130009-01,"Standard Silver On Exchange Plan",,0.717542626,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$24,000 ","$24000 per person | $48000 per group","$33,000 ","$33000 per person | $66000 per group",,,,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",40.00%,,,,"$19,500 ","$19500 per person | $39000 per group","$27,500 ","$27500 per person | $55000 per group","$8,000 ","$0 ","$1,000 ","$60 ","$900 ","$400 ","$0 ","$20 ",,,Yes,"LINK SILVER OPTION 2","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0130010,"LINK BRONZE  EXPANDED",38128ID013,,IDN004,IDS005,IDF006,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0130010-01,"Standard Bronze On Exchange Plan",,0.649870744,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17200 per group",,,"$25,000 ","$25000 per person | $50000 per group","$33,900 ","$33900 per person | $67800 per group",,,,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17200 per group",0.00%,,,,"$25,000 ","$25000 per person | $50000 per group","$33,900 ","$33900 per person | $67800 per group","$8,900 ","$0 ","$0 ","$60 ","$4,700 ","$0 ","$0 ","$20 ",,,Yes,"LINK BRONZE  EXPANDED","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0130011,"LINK PLATINUM ",38128ID013,,IDN004,IDS005,IDF004,New,POS,Platinum,No,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0130011-01,"Standard Platinum On Exchange Plan",,0.907475337,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",,,"$4,000 ","$4000 per person | $8000 per group","$5,500 ","$5500 per person | $11000 per group",,,,,,,,,,,,,,,,,,,,,"$500 ","$500 per person | $1000 per group",10.00%,,,,"$2,000 ","$2000 per person | $4000 per group","$2,500 ","$2500 per person | $5000 per group","$500 ","$0 ","$1,000 ","$60 ","$500 ","$300 ","$40 ","$20 ",,,Yes,"LINK PLATINUM ","$500 ","$100 ","$300 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140001,"ENGAGE  GOLD",38128ID014,,IDN002,IDS003,IDF001,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140001-01,"Standard Gold On Exchange Plan",,0.809580768,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",,,"$18,000 ","$18000 per person | $36000 per group","$24,500 ","$24500 per person | $49000 per group",,,,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",30.00%,,,,"$2,250 ","$2250 per person | $4500 per group","$3,250 ","$3250 per person | $6500 per group","$1,000 ","$10 ","$3,600 ","$60 ","$900 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE  GOLD","$1,000 ","$200 ","$500 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140001,"ENGAGE  GOLD",38128ID014,,IDN002,IDS003,IDF001,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140001-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE  GOLD","$0 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140001,"ENGAGE  GOLD",38128ID014,,IDN002,IDS003,IDF001,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140001-03,"Limited Cost Sharing Plan Variation",,0.809580768,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",,,"$18,000 ","$18000 per person | $36000 per group","$24,500 ","$24500 per person | $49000 per group",,,,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",30.00%,,,,"$2,250 ","$2250 per person | $4500 per group","$3,250 ","$3250 per person | $6500 per group","$1,000 ","$10 ","$3,600 ","$60 ","$900 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE  GOLD","$1,000 ","$200 ","$500 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140002,"ENGAGE  SILVER",38128ID014,,IDN002,IDS003,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140002-01,"Standard Silver On Exchange Plan",,0.708056097,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,150 ","$8150 per person | $16300 per group",,,"$24,450 ","$24450 per person | $48900 per group","$32,600 ","$32600 per person | $65200 per group",,,,,,,,,,,,,,,,,,,,,"$5,700 ","$5700 per person | $11400 per group",30.00%,,,,"$17,100 ","$17100 per person | $34200 per group","$22,800 ","$22800 per person | $45600 per group","$6,500 ","$0 ","$2,000 ","$60 ","$900 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE  SILVER","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140002,"ENGAGE  SILVER",38128ID014,,IDN002,IDS003,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140002-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE  SILVER","$0 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140002,"ENGAGE  SILVER",38128ID014,,IDN002,IDS003,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140002-03,"Limited Cost Sharing Plan Variation",,0.708056097,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,150 ","$8150 per person | $16300 per group",,,"$24,450 ","$24450 per person | $48900 per group","$32,600 ","$32600 per person | $65200 per group",,,,,,,,,,,,,,,,,,,,,"$5,700 ","$5700 per person | $11400 per group",30.00%,,,,"$17,100 ","$17100 per person | $34200 per group","$22,800 ","$22800 per person | $45600 per group","$6,500 ","$0 ","$2,000 ","$60 ","$900 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE  SILVER","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140002,"ENGAGE  SILVER",38128ID014,,IDN002,IDS003,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140002-04,"73% AV Level Silver Plan",,0.734776321,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,600 ","$6600 per person | $13200 per group",,,"$19,800 ","$19800 per person | $39600 per group","$26,400 ","$26400 per person | $52800 per group",,,,,,,,,,,,,,,,,,,,,"$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$13,500 ","$13500 per person | $27000 per group","$18,000 ","$18000 per person | $36000 per group","$5,000 ","$0 ","$2,400 ","$60 ","$900 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE  SILVER","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140002,"ENGAGE  SILVER",38128ID014,,IDN002,IDS003,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140002-05,"87% AV Level Silver Plan",,0.875117023,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,800 ","$2800 per person | $5600 per group",,,"$8,400 ","$8400 per person | $16800 per group","$11,200 ","$11200 per person | $22400 per group",,,,,,,,,,,,,,,,,,,,,"$600 ","$600 per person | $1200 per group",30.00%,,,,"$1,800 ","$1800 per person | $3600 per group","$2,400 ","$2400 per person | $4800 per group","$750 ","$0 ","$1,900 ","$60 ","$750 ","$400 ","$50 ","$20 ",100%,"Not Applicable",No,"ENGAGE  SILVER","$750 ","$200 ","$600 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140002,"ENGAGE  SILVER",38128ID014,,IDN002,IDS003,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140002-06,"94% AV Level Silver Plan",,0.947967664,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",,,"$3,000 ","$3000 per person | $6000 per group","$4,000 ","$4000 per person | $8000 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",20.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$1,000 ","$60 ","$0 ","$200 ","$200 ","$20 ",100%,"Not Applicable",No,"ENGAGE  SILVER","$0 ","$100 ","$700 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140003,"ENGAGE  BRONZE ",38128ID014,,IDN002,IDS003,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140003-01,"Standard Bronze On Exchange Plan",,0.649572897,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",,,"$17,100 ","$17100 per person | $34200 per group","$25,800 ","$25800 per person | $51600 per group",,,,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",0.00%,,,,"$17,100 ","$17100 per person | $34200 per group","$25,800 ","$25800 per person | $51600 per group","$8,900 ","$0 ","$0 ","$60 ","$4,400 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE  BRONZE ","$2,500 ","$300 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140003,"ENGAGE  BRONZE ",38128ID014,,IDN002,IDS003,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140003-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE  BRONZE ","$0 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140003,"ENGAGE  BRONZE ",38128ID014,,IDN002,IDS003,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140003-03,"Limited Cost Sharing Plan Variation",,0.649572897,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",,,"$17,100 ","$17100 per person | $34200 per group","$25,800 ","$25800 per person | $51600 per group",,,,,,,,,,,,,,,,,,,,,"$8,700 ","$8700 per person | $17400 per group",0.00%,,,,"$17,100 ","$17100 per person | $34200 per group","$25,800 ","$25800 per person | $51600 per group","$8,900 ","$0 ","$0 ","$60 ","$4,400 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE  BRONZE ","$2,500 ","$300 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140004,"ENGAGE SILVER OPTION 2",38128ID014,,IDN002,IDS003,IDF001,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140004-01,"Standard Silver On Exchange Plan",,0.714385694,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$24,000 ","$24000 per person | $48000 per group","$33,000 ","$33000 per person | $66000 per group",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$19,500 ","$19500 per person | $39000 per group","$27,000 ","$27000 per person | $54000 per group","$7,500 ","$0 ","$1,500 ","$60 ","$900 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE SILVER OPTION 2","$100 ","$2,700 ","$2,500 ","$200 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140004,"ENGAGE SILVER OPTION 2",38128ID014,,IDN002,IDS003,IDF001,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140004-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE SILVER OPTION 2","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140004,"ENGAGE SILVER OPTION 2",38128ID014,,IDN002,IDS003,IDF001,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140004-03,"Limited Cost Sharing Plan Variation",,0.714385694,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$24,000 ","$24000 per person | $48000 per group","$33,000 ","$33000 per person | $66000 per group",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$19,500 ","$19500 per person | $39000 per group","$27,000 ","$27000 per person | $54000 per group","$7,500 ","$0 ","$1,500 ","$60 ","$900 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE SILVER OPTION 2","$100 ","$2,700 ","$2,500 ","$200 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140004,"ENGAGE SILVER OPTION 2",38128ID014,,IDN002,IDS003,IDF001,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140004-04,"73% AV Level Silver Plan",,0.736677137,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group",,,,,,,,,,,,,,,,,,,,,"$6,700 ","$6700 per person | $13400 per group",40.00%,,,,"$19,500 ","$19500 per person | $39000 per group","$26,200 ","$26200 per person | $52400 per group","$6,700 ","$0 ","$800 ","$60 ","$900 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE SILVER OPTION 2","$100 ","$2,700 ","$2,500 ","$200 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140004,"ENGAGE SILVER OPTION 2",38128ID014,,IDN002,IDS003,IDF001,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140004-05,"87% AV Level Silver Plan",,0.875966158,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,800 ","$2800 per person | $5600 per group",,,"$8,400 ","$8400 per person | $16800 per group","$11,200 ","$11200 per person | $22400 per group",,,,,,,,,,,,,,,,,,,,,"$800 ","$800 per person | $1600 per group",30.00%,,,,"$2,400 ","$2400 per person | $4800 per group","$3,200 ","$3200 per person | $6400 per group","$800 ","$0 ","$2,000 ","$60 ","$800 ","$200 ","$30 ","$20 ",100%,"Not Applicable",No,"ENGAGE SILVER OPTION 2","$1,300 ","$1,500 ","$800 ","$100 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140004,"ENGAGE SILVER OPTION 2",38128ID014,,IDN002,IDS003,IDF001,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140004-06,"94% AV Level Silver Plan",,0.9467343,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",,,"$2,700 ","$2700 per person | $5400 per group","$3,700 ","$3700 per person | $7400 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",20.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$1,000 ","$60 ","$0 ","$200 ","$200 ","$20 ",100%,"Not Applicable",No,"ENGAGE SILVER OPTION 2","$2,000 ","$800 ","$0 ","$100 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140005,"ENGAGE CATASTROPHIC ",38128ID014,,IDN002,IDS003,IDF003,Existing,POS,Catastrophic,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,3,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140005-01,"Standard Catastrophic On Exchange Plan",,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$27,300 ","$27300 per person | $54600 per group","$36,750 ","$36750 per person | $73500 per group",,,,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",0.00%,,,,"$27,300 ","$27300 per person | $54600 per group","$36,750 ","$36750 per person | $73500 per group","$9,450 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE CATASTROPHIC ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140006,"ENGAGE BRONZE HDHP ",38128ID014,,IDN002,IDS003,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,Yes,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140006-01,"Standard Bronze On Exchange Plan",,0.639604829,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group","$7,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE BRONZE HDHP ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140006,"ENGAGE BRONZE HDHP ",38128ID014,,IDN002,IDS003,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140006-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE BRONZE HD","$0 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0140006,"ENGAGE BRONZE HDHP ",38128ID014,,IDN002,IDS003,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0140006-03,"Limited Cost Sharing Plan Variation",,0.639604829,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group","$7,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ENGAGE BRONZE HD","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0150001,"ENGAGE GOLD ",38128ID015,,IDN005,IDS004,IDF004,Existing,POS,Gold,No,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0150001-01,"Standard Gold On Exchange Plan",,0.809634873,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",,,"$18,000 ","$18000 per person | $36000 per group","$24,500 ","$24500 per person | $49000 per group",,,,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",30.00%,,,,"$2,250 ","$2250 per person | $4500 per group","$3,250 ","$3250 per person | $6500 per group","$1,000 ","$10 ","$3,600 ","$60 ","$900 ","$500 ","$0 ","$20 ",,,Yes,"ENGAGE GOLD ","$1,000 ","$200 ","$500 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0150002,"ENGAGE SILVER ",38128ID015,,IDN005,IDS004,IDF007,Existing,POS,Silver,No,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0150002-01,"Standard Silver On Exchange Plan",,0.709929978,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$24,450 ","$24450 per person | $48900 per group","$33,450 ","$33450 per person | $66900 per group",,,,,,,,,,,,,,,,,,,,,"$4,900 ","$4900 per person | $9800 per group",40.00%,,,,"$15,600 ","$15600 per person | $31200 per group","$21,100 ","$21100 per person | $42200 per group","$4,900 ","$10 ","$3,100 ","$60 ","$900 ","$700 ","$0 ","$20 ",,,Yes,"ENGAGE SILVER ","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0150004,"ENGAGE  SILVER  HDHP",38128ID015,,IDN005,IDS004,IDF006,Existing,POS,Silver,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0150004-01,"Standard Silver On Exchange Plan",,0.701861634,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,700 ","$5700 per person | $11400 per group",,,"$15,000 ","$15000 per person | $30000 per group","$20,700 ","$20700 per person | $41400 per group",,,,,,,,,,,,,,,,,,,,,"$5,700 ","$5700 per person | $11400 per group",0.00%,,,,"$15,000 ","$15000 per person | $30000 per group","$20,700 ","$20700 per person | $41400 per group","$5,700 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",,,Yes,"ENGAGE  SILVER  HDHP","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0150005,"ENGAGE  BRONZE HDHP",38128ID015,,IDN005,IDS004,IDF006,Existing,POS,"Expanded Bronze",No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0150005-01,"Standard Bronze On Exchange Plan",,0.639604829,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group","$7,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",,,Yes,"ENGAGE  BRONZE HDHP","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0150006,"ENGAGE SILVER OPTION 2",38128ID015,,IDN005,IDS004,IDF004,Existing,POS,Silver,No,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0150006-01,"Standard Silver On Exchange Plan",,0.714385694,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$24,000 ","$24000 per person | $48000 per group","$33,000 ","$33000 per person | $66000 per group",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$19,500 ","$19500 per person | $39000 per group","$27,000 ","$27000 per person | $54000 per group","$7,500 ","$0 ","$1,500 ","$60 ","$900 ","$600 ","$0 ","$20 ",,,Yes,"ENGAGE SILVER OPTION 2","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0150007,"ENGAGE GOLD  OPTION 2",38128ID015,,IDN005,IDS004,IDF005,Existing,POS,Gold,No,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0150007-01,"Standard Gold On Exchange Plan",,0.786363611,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",,,"$13,000 ","$13000 per person | $26000 per group","$19,500 ","$19500 per person | $39000 per group",,,,,,,,,,,,,,,,,,,,,"$1,800 ","$1800 per person | $3600 per group",30.00%,,,,"$3,200 ","$3200 per person | $6400 per group","$5,000 ","$5000 per person | $10000 per group","$1,800 ","$10 ","$3,400 ","$60 ","$900 ","$600 ","$0 ","$20 ",,,Yes,"ENGAGE GOLD OPTION 2","$1,800 ","$200 ","$200 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,38128ID0150008,"ENGAGE  BRONZE EXPANDED",38128ID015,,IDN005,IDS004,IDF006,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",Yes,,,,,38128ID0150008-01,"Standard Bronze On Exchange Plan",,0.641144888,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$25,000 ","$25000 per person | $50000 per group","$34,100 ","$34100 per person | $68200 per group",,,,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",0.00%,,,,"$25,000 ","$25000 per person | $50000 per group","$34,100 ","$34100 per person | $68200 per group","$9,100 ","$0 ","$0 ","$60 ","$4,400 ","$500 ","$0 ","$20 ",,,Yes,"ENGAGE  BRONZE EXPANDED","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160001,"ACCESS GOLD",38128ID016,,IDN003,IDS002,IDF001,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160001-01,"Standard Gold On Exchange Plan",,0.809580768,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",,,"$18,000 ","$18000 per person | $36000 per group","$24,500 ","$24500 per person | $49000 per group",,,,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",30.00%,,,,"$2,250 ","$2250 per person | $4500 per group","$3,250 ","$3250 per person | $6500 per group","$1,000 ","$10 ","$3,600 ","$60 ","$900 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"ACCESS GOLD","$1,000 ","$200 ","$500 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160001,"ACCESS GOLD",38128ID016,,IDN003,IDS002,IDF001,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160001-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ACCESS GOLD","$0 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160001,"ACCESS GOLD",38128ID016,,IDN003,IDS002,IDF001,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160001-03,"Limited Cost Sharing Plan Variation",,0.809580768,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",,,"$18,000 ","$18000 per person | $36000 per group","$24,500 ","$24500 per person | $49000 per group",,,,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",30.00%,,,,"$2,250 ","$2250 per person | $4500 per group","$3,250 ","$3250 per person | $6500 per group","$1,000 ","$10 ","$3,600 ","$60 ","$900 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"ACCESS GOLD","$1,000 ","$200 ","$500 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160002,"ACCESS  SILVER ",38128ID016,,IDN003,IDS002,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160002-01,"Standard Silver On Exchange Plan",,0.718866333,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,500 ","$8500 per person | $17000 per group",,,"$17,000 ","$17000 per person | $34000 per group","$25,500 ","$25500 per person | $51000 per group",,,,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",40.00%,,,,"$9,000 ","$9000 per person | $18000 per group","$15,500 ","$15500 per person | $31000 per group","$6,500 ","$0 ","$2,000 ","$60 ","$900 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"ACCESS  SILVER ","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160002,"ACCESS  SILVER ",38128ID016,,IDN003,IDS002,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160002-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ACCESS  SILVER ","$0 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160002,"ACCESS  SILVER ",38128ID016,,IDN003,IDS002,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160002-03,"Limited Cost Sharing Plan Variation",,0.718866333,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,500 ","$8500 per person | $17000 per group",,,"$17,000 ","$17000 per person | $34000 per group","$25,500 ","$25500 per person | $51000 per group",,,,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",40.00%,,,,"$9,000 ","$9000 per person | $18000 per group","$15,500 ","$15500 per person | $31000 per group","$6,500 ","$0 ","$2,000 ","$60 ","$900 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"ACCESS  SILVER ","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160002,"ACCESS  SILVER ",38128ID016,,IDN003,IDS002,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160002-04,"73% AV Level Silver Plan",,0.739618707,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,400 ","$7400 per person | $14800 per group",,,"$14,000 ","$14000 per person | $28000 per group","$21,400 ","$21400 per person | $42800 per group",,,,,,,,,,,,,,,,,,,,,"$5,000 ","$5000 per person | $10000 per group",40.00%,,,,"$7,000 ","$7000 per person | $14000 per group","$12,000 ","$12000 per person | $24000 per group","$5,000 ","$0 ","$2,400 ","$60 ","$900 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"ACCESS  SILVER ","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160002,"ACCESS  SILVER ",38128ID016,,IDN003,IDS002,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160002-05,"87% AV Level Silver Plan",,0.874370708,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,600 ","$2600 per person | $5200 per group",,,"$5,200 ","$5200 per person | $10400 per group","$7,800 ","$7800 per person | $15600 per group",,,,,,,,,,,,,,,,,,,,,"$750 ","$750 per person | $1500 per group",30.00%,,,,"$1,500 ","$1500 per person | $3000 per group","$2,250 ","$2250 per person | $4500 per group","$750 ","$0 ","$1,900 ","$60 ","$750 ","$400 ","$50 ","$20 ",100%,"Not Applicable",No,"ACCESS  SILVER ","$750 ","$200 ","$600 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160002,"ACCESS  SILVER ",38128ID016,,IDN003,IDS002,IDF002,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160002-06,"94% AV Level Silver Plan",,0.94456671,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",,,"$2,200 ","$2200 per person | $4400 per group","$3,200 ","$3200 per person | $6400 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",20.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$1,000 ","$60 ","$0 ","$200 ","$200 ","$20 ",100%,"Not Applicable",No,"ACCESS  SILVER ","$0 ","$100 ","$700 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160003,"ACCESS BRONZE ",38128ID016,,IDN003,IDS002,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160003-01,"Standard Bronze On Exchange Plan",,0.648494845,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$25,000 ","$25000 per person | $50000 per group","$33,900 ","$33900 per person | $67800 per group",,,,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",0.00%,,,,"$25,000 ","$25000 per person | $50000 per group","$33,900 ","$33900 per person | $67800 per group","$8,900 ","$0 ","$0 ","$60 ","$4,400 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"ACCESS BRONZE ","$2,500 ","$300 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160003,"ACCESS BRONZE ",38128ID016,,IDN003,IDS002,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160003-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ACCESS BRONZE ","$0 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160003,"ACCESS BRONZE ",38128ID016,,IDN003,IDS002,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160003-03,"Limited Cost Sharing Plan Variation",,0.648494845,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$25,000 ","$25000 per person | $50000 per group","$33,900 ","$33900 per person | $67800 per group",,,,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",0.00%,,,,"$25,000 ","$25000 per person | $50000 per group","$33,900 ","$33900 per person | $67800 per group","$8,900 ","$0 ","$0 ","$60 ","$4,400 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"ACCESS BRONZE ","$2,500 ","$300 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160004,"ACCESS BRONZE HDHP",38128ID016,,IDN003,IDS002,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,Yes,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160004-01,"Standard Bronze On Exchange Plan",,0.639604829,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group","$7,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ACCESS BRONZE HDHP","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160004,"ACCESS BRONZE HDHP",38128ID016,,IDN003,IDS002,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160004-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ACCESS BRONZE HD","$0 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160004,"ACCESS BRONZE HDHP",38128ID016,,IDN003,IDS002,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160004-03,"Limited Cost Sharing Plan Variation",,0.639604829,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$21,000 ","$21000 per person | $42000 per group","$28,500 ","$28500 per person | $57000 per group","$7,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ACCESS BRONZE HD","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,38128,SERFF,1,2/12/2024,,Individual,No,,38128ID0160005,"ACCESS CATASTROPHIC ",38128ID016,,IDN003,IDS002,IDF003,Existing,POS,Catastrophic,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Diabetes, Asthma",,,,,,3,1/1/2024,12/31/2024,Yes,"Emergent Only",Yes,"Emergent Only",No,,,,,38128ID0160005-01,"Standard Catastrophic On Exchange Plan",,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$27,300 ","$27300 per person | $54600 per group","$36,750 ","$36750 per person | $73500 per group",,,,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",0.00%,,,,"$27,300 ","$27300 per person | $54600 per group","$36,750 ","$36750 per person | $73500 per group","$9,450 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"ACCESS CATASTROPHIC ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290012,"SLHP Gold 1500",44648ID129,,IDN002,IDS002,IDF007,Existing,PPO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290012-01,"Standard Gold On Exchange Plan",,0.783305508,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",20.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$17,800 ","$17800 per person | $35600 per group","$1,500 ","$10 ","$2,100 ","$60 ","$900 ","$300 ","$600 ","$200 ",100%,"Not Applicable",No,"SLHP Gold 1500","$1,500 ","$200 ","$200 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290012,"SLHP Gold 1500",44648ID129,,IDN002,IDS002,IDF007,Existing,PPO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290012-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"SLHP Gold 1500","$0 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290012,"SLHP Gold 1500",44648ID129,,IDN002,IDS002,IDF007,Existing,PPO,Gold,No,Both,No,Yes,"A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.",,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290012-03,"Limited Cost Sharing Plan Variation",,0.783305508,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",20.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$17,800 ","$17800 per person | $35600 per group","$1,500 ","$10 ","$2,100 ","$60 ","$900 ","$300 ","$600 ","$200 ",100%,"Not Applicable",No,"SLHP Gold 1500","$1,500 ","$200 ","$200 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290015,"SLHP Silver 5500 Separate RX Deductible",44648ID129,,IDN002,IDS002,IDF007,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290015-01,"Standard Silver On Exchange Plan",,0.700996788,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group","$5,500 ","$5500 per person | $11000 per group",20.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$21,800 ","$21800 per person | $43600 per group","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$2,000 ","$2000 per person | $4000 per group","$4,000 ","$4000 per person | $8000 per group",,,,,,,,,,,"$5,500 ","$10 ","$1,300 ","$60 ","$900 ","$400 ","$600 ","$200 ",100%,"Not Applicable",No,"SLHP Silver 5500 Separate RX Deductible","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290015,"SLHP Silver 5500 Separate RX Deductible",44648ID129,,IDN002,IDS002,IDF007,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290015-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"SLHP Silver 5500 Separate RX Deductible","$0 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290015,"SLHP Silver 5500 Separate RX Deductible",44648ID129,,IDN002,IDS002,IDF007,Existing,PPO,Silver,No,Both,No,Yes,"A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.",,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290015-03,"Limited Cost Sharing Plan Variation",,0.700996788,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group","$5,500 ","$5500 per person | $11000 per group",20.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$21,800 ","$21800 per person | $43600 per group","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$2,000 ","$2000 per person | $4000 per group","$4,000 ","$4000 per person | $8000 per group",,,,,,,,,,,"$5,500 ","$10 ","$1,300 ","$60 ","$900 ","$400 ","$600 ","$200 ",100%,"Not Applicable",No,"SLHP Silver 5500 Separate RX Deductible","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290015,"SLHP Silver 5500 Separate RX Deductible",44648ID129,,IDN002,IDS002,IDF007,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290015-04,"73% AV Level Silver Plan",,0.736293183,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$81,500 ","$81500 per person | $163000 per group","$88,750 ","$88750 per person | $177500 per group","$4,000 ","$4000 per person | $8000 per group",20.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$20,300 ","$20300 per person | $40600 per group","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$2,000 ","$2000 per person | $4000 per group","$4,000 ","$4000 per person | $8000 per group",,,,,,,,,,,"$4,000 ","$10 ","$1,600 ","$60 ","$900 ","$400 ","$600 ","$200 ",100%,"Not Applicable",No,"SLHP Silver 5500 Separate RX Deductible","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290015,"SLHP Silver 5500 Separate RX Deductible",44648ID129,,IDN002,IDS002,IDF007,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290015-05,"87% AV Level Silver Plan",,0.87171389,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,150 ","$3150 per person | $6300 per group",,,"$81,500 ","$81500 per person | $163000 per group","$84,650 ","$84650 per person | $169300 per group","$1,000 ","$1000 per person | $2000 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$17,300 ","$17300 per person | $34600 per group","$200 ","$200 per person | $400 per group",20.00%,,,,"$200 ","$200 per person | $400 per group","$400 ","$400 per person | $800 per group",,,,,,,,,,,"$1,000 ","$10 ","$1,100 ","$60 ","$900 ","$200 ","$600 ","$200 ",100%,"Not Applicable",No,"SLHP Silver 5500 Separate RX Deductible","$1,000 ","$80 ","$100 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290015,"SLHP Silver 5500 Separate RX Deductible",44648ID129,,IDN002,IDS002,IDF007,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290015-06,"94% AV Level Silver Plan",,0.941952611,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",,,"$81,500 ","$81500 per person | $163000 per group","$82,500 ","$82500 per person | $165000 per group","$100 ","$100 per person | $200 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$16,400 ","$16400 per person | $34600 per group","$50 ","$50 per person | $100 per group",20.00%,,,,"$50 ","$50 per person | $100 per group","$100 ","$100 per person | $200 per group",,,,,,,,,,,"$100 ","$0 ","$900 ","$60 ","$100 ","$200 ","$700 ","$200 ",100%,"Not Applicable",No,"SLHP Silver 5500 Separate RX Deductible","$100 ","$70 ","$200 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290017,"SLHP Bronze HSA 7000",44648ID129,,IDN002,IDS002,IDF003,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,Yes,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290017-01,"Standard Bronze On Exchange Plan",,0.629815175,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,050 ","$8050 per person | $16100 per group",,,"$81,500 ","$81500 per person | $163000 per group","$89,550 ","$89550 per person | $179100 per group",,,,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",50.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$23,300 ","$23300 per person | $46600 per group","$7,000 ","$0 ","$500 ","$60 ","$2,000 ","$0 ","$1,200 ","$200 ",100%,"Not Applicable",No,"SLHP Bronze HSA 7000","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290017,"SLHP Bronze HSA 7000",44648ID129,,IDN002,IDS002,IDF003,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290017-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"SLHP Bronze High Deductible 7000","$0 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290017,"SLHP Bronze HSA 7000",44648ID129,,IDN002,IDS002,IDF003,Existing,PPO,"Expanded Bronze",No,Both,No,Yes,"A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.",,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290017-03,"Limited Cost Sharing Plan Variation",,0.629815175,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,050 ","$8050 per person | $16100 per group",,,"$81,500 ","$81500 per person | $163000 per group","$89,550 ","$89550 per person | $179100 per group",,,,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",50.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$23,300 ","$23300 per person | $46600 per group","$7,000 ","$0 ","$500 ","$60 ","$2,000 ","$0 ","$1,200 ","$200 ",100%,"Not Applicable",No,"SLHP Bronze High Deductible 7000","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290018,"SLHP Bronze Essential 8500 With 4 Copay No Deductible Office Visits",44648ID129,,IDN002,IDS002,IDF009,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,4,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290018-01,"Standard Bronze On Exchange Plan",,0.629929747,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$8,500 ","$8500 per person | $17000 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$24,800 ","$24800 per person | $49600 per group","$8,500 ","$10 ","$400 ","$60 ","$900 ","$500 ","$900 ","$200 ",100%,"Not Applicable",No,"SLHP Bronze Essential 8500 With 4 Copay No Deductible Office Visits","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290018,"SLHP Bronze Essential 8500 With 4 Copay No Deductible Office Visits",44648ID129,,IDN002,IDS002,IDF009,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290018-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"SLHP Bronze Essential 8500 With 4 Copay No Deductible Office Visits","$0 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290018,"SLHP Bronze Essential 8500 With 4 Copay No Deductible Office Visits",44648ID129,,IDN002,IDS002,IDF009,Existing,PPO,"Expanded Bronze",No,Both,No,Yes,"A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.",,No,,,"Allows Adult and Child-Only",,No,,,,,,,4,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290018-03,"Limited Cost Sharing Plan Variation",,0.629929747,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$8,500 ","$8500 per person | $17000 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$24,800 ","$24800 per person | $49600 per group","$8,500 ","$10 ","$400 ","$60 ","$900 ","$500 ","$900 ","$200 ",100%,"Not Applicable",No,"SLHP Bronze Essential 8500 With 4 Copay No Deductible Office Visits","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290021,"SLHP Bronze 7000",44648ID129,,IDN002,IDS002,IDF010,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290021-01,"Standard Bronze On Exchange Plan",,0.646714747,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",50.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$23,300 ","$23300 per person | $46600 per group","$7,000 ","$0 ","$2,500 ","$60 ","$900 ","$500 ","$1,600 ","$200 ",100%,"Not Applicable",No,"SLHP Bronze 7000","$2,500 ","$300 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290021,"SLHP Bronze 7000",44648ID129,,IDN002,IDS002,IDF010,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290021-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"SLHP Bronze 7000","$0 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290021,"SLHP Bronze 7000",44648ID129,,IDN002,IDS002,IDF010,Existing,PPO,"Expanded Bronze",No,Both,No,Yes,"A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.",,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290021-03,"Limited Cost Sharing Plan Variation",,0.646714747,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",50.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$23,300 ","$23300 per person | $46600 per group","$7,000 ","$0 ","$2,500 ","$60 ","$900 ","$500 ","$1,600 ","$200 ",100%,"Not Applicable",No,"SLHP Bronze 7000","$2,500 ","$300 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290025,"SLHP Silver 5000",44648ID129,,IDN002,IDS002,IDF008,New,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290025-01,"Standard Silver On Exchange Plan",,0.700915353,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$5,000 ","$5000 per person | $10000 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$21,300 ","$21300 per person | $42600 per group","$5,000 ","$10 ","$700 ","$60 ","$1,200 ","$200 ","$900 ","$200 ",100%,"Not Applicable",No,"SLHP Silver 5000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290025,"SLHP Silver 5000",44648ID129,,IDN002,IDS002,IDF008,New,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290025-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"SLHP Silver 5000","$0 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290025,"SLHP Silver 5000",44648ID129,,IDN002,IDS002,IDF008,New,PPO,Silver,No,Both,No,Yes,"A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.",,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290025-03,"Limited Cost Sharing Plan Variation",,0.700915353,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$5,000 ","$5000 per person | $10000 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$21,300 ","$21300 per person | $42600 per group","$5,000 ","$10 ","$700 ","$60 ","$1,200 ","$200 ","$900 ","$200 ",100%,"Not Applicable",No,"SLHP Silver 5000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290025,"SLHP Silver 5000",44648ID129,,IDN002,IDS002,IDF008,New,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290025-04,"73% AV Level Silver Plan",,0.730438352,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$81,500 ","$81500 per person | $163000 per group","$89,050 ","$89050 per person | $178100 per group",,,,,,,,,,,,,,,,,,,,,"$4,200 ","$4200 per person | $8400 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$20,500 ","$20500 per person | $41000 per group","$4,200 ","$10 ","$800 ","$60 ","$1,200 ","$200 ","$600 ","$200 ",100%,"Not Applicable",No,"SLHP Silver 5000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290025,"SLHP Silver 5000",44648ID129,,IDN002,IDS002,IDF008,New,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290025-05,"87% AV Level Silver Plan",,0.871661983,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,150 ","$3150 per person | $6300 per group",,,"$81,500 ","$81500 per person | $163000 per group","$84,650 ","$84650 per person | $169300 per group",,,,,,,,,,,,,,,,,,,,,"$900 ","$900 per person | $1800 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$17,200 ","$17200 per person | $34400 per group","$900 ","$10 ","$1,100 ","$60 ","$900 ","$200 ","$700 ","$200 ",100%,"Not Applicable",No,"SLHP Silver 5000","$900 ","$10 ","$200 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1290025,"SLHP Silver 5000",44648ID129,,IDN002,IDS002,IDF008,New,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1290025-06,"94% AV Level Silver Plan",,0.940737732,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,000 ","$2000 per person | $4000 per group",,,"$81,500 ","$81500 per person | $163000 per group","$83,500 ","$83500 per person | $167000 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$16,300 ","$16300 per person | $32600 per group","$0 ","$10 ","$1,200 ","$60 ","$0 ","$200 ","$700 ","$200 ",100%,"Not Applicable",No,"SLHP Silver 5000","$0 ","$10 ","$300 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310007,"IAFN Gold 1500 POS",44648ID131,,IDN001,IDS001,IDF007,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310007-01,"Standard Gold On Exchange Plan",,0.783305508,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",20.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$17,800 ","$17800 per person | $35600 per group","$1,500 ","$10 ","$2,100 ","$60 ","$900 ","$300 ","$600 ","$200 ",99%,"Not Applicable",No,"IAFN Gold 1500 POS","$1,500 ","$200 ","$200 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310007,"IAFN Gold 1500 POS",44648ID131,,IDN001,IDS001,IDF007,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310007-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",99%,"Not Applicable",No,"IAFN Gold 1500 POS","$0 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310007,"IAFN Gold 1500 POS",44648ID131,,IDN001,IDS001,IDF007,Existing,POS,Gold,No,Both,No,Yes,"A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.",,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310007-03,"Limited Cost Sharing Plan Variation",,0.783305508,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",20.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$17,800 ","$17800 per person | $35600 per group","$1,500 ","$10 ","$2,100 ","$60 ","$900 ","$300 ","$600 ","$200 ",99%,"Not Applicable",No,"IAFN Gold 1500 POS","$1,500 ","$200 ","$200 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310008,"IAFN Silver 5500 Separate RX Deductible POS",44648ID131,,IDN001,IDS001,IDF007,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310008-01,"Standard Silver On Exchange Plan",,0.700996788,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group","$5,500 ","$5500 per person | $11000 per group",20.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$21,800 ","$21800 per person | $43600 per group","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$2,000 ","$2000 per person | $4000 per group","$4,000 ","$4000 per person | $8000 per group",,,,,,,,,,,"$5,500 ","$10 ","$1,300 ","$60 ","$900 ","$400 ","$600 ","$200 ",99%,"Not Applicable",No,"IAFN Silver 5500 Separate RX Deductible POS","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310008,"IAFN Silver 5500 Separate RX Deductible POS",44648ID131,,IDN001,IDS001,IDF007,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310008-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",99%,"Not Applicable",No,"IAFN Silver 5500 Separate RX Deductible POS","$0 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310008,"IAFN Silver 5500 Separate RX Deductible POS",44648ID131,,IDN001,IDS001,IDF007,Existing,POS,Silver,No,Both,No,Yes,"A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.",,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310008-03,"Limited Cost Sharing Plan Variation",,0.700996788,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group","$5,500 ","$5500 per person | $11000 per group",20.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$21,800 ","$21800 per person | $43600 per group","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$2,000 ","$2000 per person | $4000 per group","$4,000 ","$4000 per person | $8000 per group",,,,,,,,,,,"$5,500 ","$10 ","$1,300 ","$60 ","$900 ","$400 ","$600 ","$200 ",99%,"Not Applicable",No,"IAFN Silver 5500 Separate RX Deductible POS","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310008,"IAFN Silver 5500 Separate RX Deductible POS",44648ID131,,IDN001,IDS001,IDF007,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310008-04,"73% AV Level Silver Plan",,0.736293183,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$81,500 ","$81500 per person | $163000 per group","$88,750 ","$88750 per person | $177500 per group","$4,000 ","$4000 per person | $8000 per group",20.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$20,300 ","$20300 per person | $40600 per group","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$2,000 ","$2000 per person | $4000 per group","$4,000 ","$4000 per person | $8000 per group",,,,,,,,,,,"$3,500 ","$11 ","$1,743 ","$61 ","$877 ","$384 ","$937 ","$178 ",99%,"Not Applicable",No,"IAFN Silver 5500 Separate RX Deductible POS","$2,454 ","$257 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310008,"IAFN Silver 5500 Separate RX Deductible POS",44648ID131,,IDN001,IDS001,IDF007,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310008-05,"87% AV Level Silver Plan",,0.87171389,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,150 ","$3150 per person | $6300 per group",,,"$81,500 ","$81500 per person | $163000 per group","$84,650 ","$84650 per person | $169300 per group","$1,000 ","$1000 per person | $2000 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$17,300 ","$17300 per person | $34600 per group","$200 ","$200 per person | $400 per group",20.00%,,,,"$200 ","$200 per person | $400 per group","$400 ","$400 per person | $800 per group",,,,,,,,,,,"$1,000 ","$11 ","$1,122 ","$61 ","$877 ","$244 ","$937 ","$178 ",99%,"Not Applicable",No,"IAFN Silver 5500 Separate RX Deductible POS","$1,000 ","$80 ","$145 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310008,"IAFN Silver 5500 Separate RX Deductible POS",44648ID131,,IDN001,IDS001,IDF007,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310008-06,"94% AV Level Silver Plan",,0.941952611,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",,,"$81,500 ","$81500 per person | $163000 per group","$82,500 ","$82500 per person | $165000 per group","$100 ","$100 per person | $200 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$16,400 ","$16400 per person | $32800 per group","$50 ","$50 per person | $100 per group",20.00%,,,,"$50 ","$50 per person | $100 per group","$100 ","$100 per person | $200 per group",,,,,,,,,,,"$150 ","$0 ","$850 ","$61 ","$150 ","$155 ","$695 ","$178 ",99%,"Not Applicable",No,"IAFN Silver 5500 Separate RX Deductible POS","$150 ","$65 ","$230 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310009,"IAFN Silver 6500 POS",44648ID131,,IDN001,IDS001,IDF005,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310009-01,"Standard Silver On Exchange Plan",,0.701146636,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$22,800 ","$22800 per person | $45600 per group","$6,500 ","$9 ","$572 ","$61 ","$877 ","$311 ","$937 ","$178 ",99%,"Not Applicable",No,"IAFN Silver 6500 POS","$2,454 ","$245 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310009,"IAFN Silver 6500 POS",44648ID131,,IDN001,IDS001,IDF005,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310009-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",99%,"Not Applicable",No,"IAFN Silver 6500 POS","$0 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310009,"IAFN Silver 6500 POS",44648ID131,,IDN001,IDS001,IDF005,Existing,POS,Silver,No,Both,No,Yes,"A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.",,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310009-03,"Limited Cost Sharing Plan Variation",,0.701146636,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$22,800 ","$22800 per person | $45600 per group","$6,500 ","$9 ","$572 ","$61 ","$877 ","$311 ","$937 ","$178 ",99%,"Not Applicable",No,"IAFN Silver 6500 POS","$2,454 ","$245 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310009,"IAFN Silver 6500 POS",44648ID131,,IDN001,IDS001,IDF005,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310009-04,"73% AV Level Silver Plan",,0.734244712,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$81,500 ","$81500 per person | $163000 per group","$89,050 ","$89050 per person | $178100 per group",,,,,,,,,,,,,,,,,,,,,"$5,000 ","$5000 per person | $10000 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$21,300 ","$21300 per person | $42600 per group","$5,000 ","$9 ","$722 ","$61 ","$877 ","$311 ","$937 ","$178 ",99%,"Not Applicable",No,"IAFN Silver 6500 POS","$2,454 ","$245 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310009,"IAFN Silver 6500 POS",44648ID131,,IDN001,IDS001,IDF005,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310009-05,"87% AV Level Silver Plan",,0.871339797,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,150 ","$3150 per person | $6300 per group",,,"$81,500 ","$81500 per person | $163000 per group","$84,650 ","$84650 per person | $169300 per group",,,,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$17,300 ","$17300 per person | $34600 per group","$1,000 ","$9 ","$1,122 ","$61 ","$877 ","$251 ","$937 ","$178 ",99%,"Not Applicable",No,"IAFN Silver 6500 POS","$1,000 ","$155 ","$145 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310009,"IAFN Silver 6500 POS",44648ID131,,IDN001,IDS001,IDF005,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310009-06,"94% AV Level Silver Plan",,0.943560664,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",,,"$81,500 ","$81500 per person | $163000 per group","$83,000 ","$83000 per person | $166000 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$16,300 ","$16300 per person | $32600 per group","$200 ","$0 ","$800 ","$61 ","$200 ","$143 ","$657 ","$178 ",99%,"Not Applicable",No,"IAFN Silver 6500 POS","$200 ","$65 ","$225 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310011,"IAFN Gold 2500 POS",44648ID131,,IDN001,IDS001,IDF005,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310011-01,"Standard Gold On Exchange Plan",,0.780690421,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$2,500 ","$2500 per person | $5000 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$18,800 ","$18800 per person | $37600 per group","$2,500 ","$10 ","$1,000 ","$60 ","$900 ","$300 ","$600 ","$200 ",99%,"Not Applicable",No,"IAFN Gold 2500 POS","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310011,"IAFN Gold 2500 POS",44648ID131,,IDN001,IDS001,IDF005,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310011-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",99%,"Not Applicable",No,"IAFN Gold 2500 POS","$0 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1310011,"IAFN Gold 2500 POS",44648ID131,,IDN001,IDS001,IDF005,Existing,POS,Gold,No,Both,No,Yes,"A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.",,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1310011-03,"Limited Cost Sharing Plan Variation",,0.780690421,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$2,500 ","$2500 per person | $5000 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$18,800 ","$18800 per person | $37600 per group","$2,500 ","$10 ","$1,000 ","$60 ","$900 ","$300 ","$600 ","$200 ",99%,"Not Applicable",No,"IAFN Gold 2500 POS","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1350001,"IAFN Bronze HSA 7000 POS",44648ID135,,IDN001,IDS001,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,Yes,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1350001-01,"Standard Bronze On Exchange Plan",,0.629815175,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,050 ","$8050 per person | $16100 per group",,,"$81,500 ","$81500 per person | $163000 per group","$89,550 ","$89550 per person | $179100 per group",,,,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",50.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$23,050 ","$23050 per person | $46100 per group","$7,000 ","$0 ","$500 ","$60 ","$2,000 ","$0 ","$1,200 ","$200 ",100%,"Not Applicable",No,"IAFN Bronze HSA 7000 POS","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1350001,"IAFN Bronze HSA 7000 POS",44648ID135,,IDN001,IDS001,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1350001-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"IAFN Bronze High Deductible 7000 POS","$0 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1350001,"IAFN Bronze HSA 7000 POS",44648ID135,,IDN001,IDS001,IDF003,Existing,POS,"Expanded Bronze",No,Both,No,Yes,"A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.",,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1350001-03,"Limited Cost Sharing Plan Variation",,0.629815175,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,050 ","$8050 per person | $16100 per group",,,"$81,500 ","$81500 per person | $163000 per group","$89,550 ","$89550 per person | $179100 per group",,,,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",50.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$23,050 ","$23050 per person | $46100 per group","$7,000 ","$0 ","$500 ","$60 ","$2,000 ","$0 ","$1,200 ","$200 ",100%,"Not Applicable",No,"IAFN Bronze High Deductible 7000 POS","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1350002,"IAFN Bronze 7000 POS",44648ID135,,IDN001,IDS001,IDF010,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1350002-01,"Standard Bronze On Exchange Plan",,0.646714747,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",50.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$23,300 ","$23300 per person | $46600 per group","$7,000 ","$0 ","$2,500 ","$60 ","$900 ","$500 ","$1,600 ","$200 ",100%,"Not Applicable",No,"IAFN Bronze 7000 POS","$2,500 ","$300 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1350002,"IAFN Bronze 7000 POS",44648ID135,,IDN001,IDS001,IDF010,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1350002-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"IAFN Bronze 7000 POS","$0 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1350002,"IAFN Bronze 7000 POS",44648ID135,,IDN001,IDS001,IDF010,Existing,POS,"Expanded Bronze",No,Both,No,Yes,"A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.",,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1350002-03,"Limited Cost Sharing Plan Variation",,0.646714747,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",50.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$23,300 ","$23300 per person | $46600 per group","$7,000 ","$0 ","$2,500 ","$60 ","$900 ","$500 ","$1,600 ","$200 ",100%,"Not Applicable",No,"IAFN Bronze 7000 POS","$2,500 ","$300 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1350003,"IAFN Bronze Essential 8500 With 4 Copay No Deductible Office Visits POS",44648ID135,,IDN001,IDS001,IDF009,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,4,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1350003-01,"Standard Bronze On Exchange Plan",,0.629929747,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$8,500 ","$8500 per person | $17000 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$24,800 ","$24800 per person | $49600 per group","$8,500 ","$10 ","$400 ","$60 ","$900 ","$500 ","$900 ","$200 ",100%,"Not Applicable",No,"IAFN Bronze Essential 8500 With 4 Copay No Deductible Office Visits POS","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1350003,"IAFN Bronze Essential 8500 With 4 Copay No Deductible Office Visits POS",44648ID135,,IDN001,IDS001,IDF009,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1350003-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"IAFN Bronze Essential 8500 With 4 Copay No Deductible Office Visits POS","$0 ","$0 ","$0 ","$0 "
2024,ID,,44648,SERFF,1,2/12/2024,,Individual,No,,44648ID1350003,"IAFN Bronze Essential 8500 With 4 Copay No Deductible Office Visits POS",44648ID135,,IDN001,IDS001,IDF009,Existing,POS,"Expanded Bronze",No,Both,No,Yes,"A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.",,No,,,"Allows Adult and Child-Only",,No,,,,,,,4,1/1/2024,,Yes,"Members traveling outside the United States receive coverage for the same benefits as inside the United States. Members who do not seek inpatient care at a BlueCross BlueShield Global Hospital may have to pay a provider upfront for care and submit an international claim form to be reimbursed.",Yes,"Out of Area benefits are covered on Blue Card which provides access to the largest network of doctors in the United States",Yes,,,,,44648ID1350003-03,"Limited Cost Sharing Plan Variation",,0.629929747,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$81,500 ","$81500 per person | $163000 per group","$90,950 ","$90950 per person | $181900 per group",,,,,,,,,,,,,,,,,,,,,"$8,500 ","$8500 per person | $17000 per group",10.00%,,,,"$16,300 ","$16300 per person | $32600 per group","$24,800 ","$24800 per person | $49600 per group","$8,500 ","$10 ","$400 ","$60 ","$900 ","$500 ","$900 ","$200 ",100%,"Not Applicable",No,"IAFN Bronze Essential 8500 With 4 Copay No Deductible Office Visits POS","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,46641,SERFF,1,2/12/2024,,Individual,Yes,,46641ID0020005,"Smile Complete Adult + Preferred Pediatric",46641ID002,,IDN001,IDS001,,Existing,PPO,High,,Both,,,,"Exclusions are listed in the contract, which is included in the supporting documentation.",,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,,Yes,"Same benefit level as in country",Yes,"Same benefit level as in country",Yes,,,,,46641ID0020005-01,"Standard High On Exchange Plan",,,,,No,100%,,"$400 ","$400 per person | $800 per group",,,"$2,000 ","$2000 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"$25 ","$25 per person | per group not applicable",,,,,"$25 ","$25 per person | per group not applicable","$25 ","$25 per person | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Smile Complete Adult + Preferred Pediatric",,,,
2024,ID,,46641,SERFF,1,2/12/2024,,Individual,Yes,,46641ID0020006,"Smile Complete Adult + Basic Pediatric",46641ID002,,IDN001,IDS001,,Existing,PPO,Low,,Both,,,,"Exclusions are listed in the contract, which is included in the supporting documentation.",,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,,Yes,"Same benefit level as in country",Yes,"Same benefit level as in country",Yes,,,,,46641ID0020006-01,"Standard Low On Exchange Plan",,,,,No,100%,,"$400 ","$400 per person | $800 per group",,,"$2,000 ","$2000 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"$75 ","$75 per person | per group not applicable",,,,,"$75 ","$75 per person | per group not applicable","$75 ","$75 per person | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Smile Complete Adult + Basic Pediatric",,,,
2024,ID,,46641,SERFF,1,2/12/2024,,Individual,Yes,,46641ID0020007,"Smile Adult + Preferred Pediatric",46641ID002,,IDN001,IDS001,,Existing,PPO,High,,Both,,,,"Exclusions are listed in the contract, which is included in the supporting documentation.",,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,,Yes,"Same benefit level as in country",Yes,"Same benefit level as in country",Yes,,,,,46641ID0020007-01,"Standard High On Exchange Plan",,,,,No,100%,,"$400 ","$400 per person | $800 per group",,,"$2,000 ","$2000 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"$25 ","$25 per person | per group not applicable",,,,,"$25 ","$25 per person | per group not applicable","$25 ","$25 per person | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Smile Adult + Preferred Pediatric",,,,
2024,ID,,46641,SERFF,1,2/12/2024,,Individual,Yes,,46641ID0020008,"Smile Adult + Basic Pediatric",46641ID002,,IDN001,IDS001,,Existing,PPO,Low,,Both,,,,"Exclusions are listed in the contract, which is included in the supporting documentation.",,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,,Yes,"Same benefit level as in country",Yes,"Same benefit level as in country",Yes,,,,,46641ID0020008-01,"Standard Low On Exchange Plan",,,,,No,100%,,"$400 ","$400 per person | $800 per group",,,"$2,000 ","$2000 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"$75 ","$75 per person | per group not applicable",,,,,"$75 ","$75 per person | per group not applicable","$75 ","$75 per person | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Smile Adult + Basic Pediatric",,,,
2024,ID,,48872,SERFF,1,2/12/2024,,Individual,Yes,,48872ID0010001,"EMI Health Premier PPO (High)",48872ID001,,IDN001,IDS001,,Existing,PPO,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,91.58%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Dental expenses for care, supplies, or services which are rendered by a Provider whose principal place of business or address for payment is located outside the United States are payable under the Plan, subject to all Plan exclusions, limitations, maximums and other provisions, under the conditions outlined in the policy.",Yes,"PPO network or out-of-network coverage at PPO fee",Yes,,,,,48872ID0010001-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$375 ","$375 per person | $750 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"Not Applicable","per person not applicable | per group not applicable","$25 ","$25 per person | $75 per group",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"EMI Health Premier PPO (High)",,,,
2024,ID,,48872,SERFF,1,2/12/2024,,Individual,Yes,,48872ID0010002,"EMI Health Premier PPO (Low)",48872ID001,,IDN001,IDS001,,Existing,PPO,Low,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Dental expenses for care, supplies, or services which are rendered by a Provider whose principal place of business or address for payment is located outside the United States are payable under the Plan, subject to all Plan exclusions, limitations, maximums and other provisions, under the conditions outlined in the policy.",Yes,"PPO network or out-of-network coverage at PPO fee",Yes,,,,,48872ID0010002-01,"Standard Low On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$375 ","$375 per person | $750 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"EMI Health Premier PPO (Low)",,,,
2024,ID,,48872,SERFF,1,2/12/2024,,Individual,Yes,,48872ID0010003,"EMI Health Advantage Co-Pay",48872ID001,,IDN002,IDS001,,Existing,PPO,Low,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Dental expenses for care, supplies, or services which are rendered by a Provider whose principal place of business or address for payment is located outside the United States are payable under the Plan, subject to all Plan exclusions, limitations, maximums and other provisions, under the conditions outlined in the policy.",Yes,"PPO network or out-of-network coverage at PPO fee",Yes,,,,,48872ID0010003-01,"Standard Low On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$375 ","$375 per person | $750 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"Not Applicable","per person not applicable | per group not applicable","$50 ","$50 per person | $150 per group",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"EMI Health Advantage Co-Pay",,,,
2024,ID,,48872,SERFF,1,2/12/2024,,Individual,Yes,,48872ID0010004,"EMI Health Advantage PPO",48872ID001,,IDN002,IDS001,,Existing,PPO,Low,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Dental expenses for care, supplies, or services which are rendered by a Provider whose principal place of business or address for payment is located outside the United States are payable under the Plan, subject to all Plan exclusions, limitations, maximums and other provisions, under the conditions outlined in the policy.",Yes,"PPO network or out-of-network coverage at PPO fee",Yes,,,,,48872ID0010004-01,"Standard Low On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$375 ","$375 per person | $750 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $300 per group",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"EMI Health Advantage PPO",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350001,"Voyager Silver HSA 3500",60597ID035,,IDN005,IDS006,IDF001,Existing,PPO,Silver,No,Both,No,No,,,Yes,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350001-01,"Standard Silver On Exchange Plan",,0.709375341,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,700 ","$6700 per person | $13400 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,500 ","$3500 per person | $7000 per group",25.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$0 ","$2,300 ","$60 ","$3,500 ","$0 ","$500 ","$20 ",100%,"Not Applicable",No,"Voyager Silver 3500","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350001,"Voyager Silver HSA 3500",60597ID035,,IDN005,IDS006,IDF001,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350001-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Silver 3500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350001,"Voyager Silver HSA 3500",60597ID035,,IDN005,IDS006,IDF001,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350001-03,"Limited Cost Sharing Plan Variation",,0.709375341,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,700 ","$6700 per person | $13400 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,500 ","$3500 per person | $7000 per group",25.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Silver 3500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350001,"Voyager Silver HSA 3500",60597ID035,,IDN005,IDS006,IDF001,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350001-04,"73% AV Level Silver Plan",,0.738742155,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,400 ","$6400 per person | $12800 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$2,400 ","$2400 per person | $4800 per group",25.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$2,400 ","$0 ","$2,500 ","$60 ","$2,400 ","$0 ","$800 ","$20 ",100%,"Not Applicable",No,"Voyager Silver 3500","$2,400 ","$0 ","$100 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350001,"Voyager Silver HSA 3500",60597ID035,,IDN005,IDS006,IDF001,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350001-05,"87% AV Level Silver Plan",,0.876329941,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,800 ","$1800 per person | $3600 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$1,100 ","$1100 per person | $2200 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$1,100 ","$0 ","$700 ","$60 ","$1,100 ","$0 ","$700 ","$20 ",100%,"Not Applicable",No,"Voyager Silver 3500","$1,100 ","$0 ","$300 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350001,"Voyager Silver HSA 3500",60597ID035,,IDN005,IDS006,IDF001,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350001-06,"94% AV Level Silver Plan",,0.943965196,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$600 ","$600 per person | $1200 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$400 ","$400 per person | $800 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$400 ","$0 ","$200 ","$60 ","$400 ","$0 ","$200 ","$20 ",100%,"Not Applicable",No,"Voyager Silver 3500","$400 ","$0 ","$200 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350004,"Voyager Bronze HSA 7500",60597ID035,,IDN005,IDS006,IDF004,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,Yes,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350004-01,"Standard Bronze On Exchange Plan",,0.639604829,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Bronze HSA 7500","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350004,"Voyager Bronze HSA 7500",60597ID035,,IDN005,IDS006,IDF004,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350004-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Bronze 7500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350004,"Voyager Bronze HSA 7500",60597ID035,,IDN005,IDS006,IDF004,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350004-03,"Limited Cost Sharing Plan Variation",,0.639604829,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Bronze 7500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350005,"Voyager Bronze 6000",60597ID035,,IDN005,IDS006,IDF005,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350005-01,"Standard Bronze On Exchange Plan",,0.649236095,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,000 ","$6000 per person | $12000 per group",50.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$6,000 ","$0 ","$3,000 ","$60 ","$4,300 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Bronze 6000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350005,"Voyager Bronze 6000",60597ID035,,IDN005,IDS006,IDF005,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350005-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Bronze 6000","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350005,"Voyager Bronze 6000",60597ID035,,IDN005,IDS006,IDF005,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350005-03,"Limited Cost Sharing Plan Variation",,0.649236095,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,000 ","$6000 per person | $12000 per group",50.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Bronze 6000","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350007,"Voyager Silver 3600",60597ID035,,IDN005,IDS006,IDF006,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350007-01,"Standard Silver On Exchange Plan",,0.717828581,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$3,600 ","$3600 per person | $7200 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$3,600 ","$0 ","$3,600 ","$60 ","$3,600 ","$300 ","$400 ","$20 ",100%,"Not Applicable",No,"Voyager Silver 3600","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350007,"Voyager Silver 3600",60597ID035,,IDN005,IDS006,IDF006,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350007-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Silver 3600","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350007,"Voyager Silver 3600",60597ID035,,IDN005,IDS006,IDF006,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350007-03,"Limited Cost Sharing Plan Variation",,0.717828581,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$3,600 ","$3600 per person | $7200 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Silver 3600","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350007,"Voyager Silver 3600",60597ID035,,IDN005,IDS006,IDF006,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350007-04,"73% AV Level Silver Plan",,0.739544847,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$3,300 ","$3300 per person | $6600 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$3,300 ","$10 ","$3,700 ","$60 ","$1,200 ","$1,200 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Silver 3600","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350007,"Voyager Silver 3600",60597ID035,,IDN005,IDS006,IDF006,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350007-05,"87% AV Level Silver Plan",,0.876923861,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,200 ","$2200 per person | $4400 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$1,100 ","$1100 per person | $2200 per group",25.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$1,100 ","$0 ","$1,100 ","$60 ","$1,100 ","$1,100 ","$20 ","$20 ",100%,"Not Applicable",No,"Voyager Silver 3600","$1,100 ","$10 ","$400 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350007,"Voyager Silver 3600",60597ID035,,IDN005,IDS006,IDF006,Existing,PPO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350007-06,"94% AV Level Silver Plan",,0.943846847,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$650 ","$650 per person | $1300 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$400 ","$0 ","$300 ","$60 ","$400 ","$200 ","$30 ","$20 ",100%,"Not Applicable",No,"Voyager Silver 3600","$400 ","$0 ","$300 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350008,"Voyager Gold 2500",60597ID035,,IDN005,IDS006,IDF007,Existing,PPO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350008-01,"Standard Gold On Exchange Plan",,0.817277417,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,000 ","$6000 per person | $12000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",10.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",10.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$2,500 ","$10 ","$1,000 ","$60 ","$900 ","$1,200 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Gold 2500","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350008,"Voyager Gold 2500",60597ID035,,IDN005,IDS006,IDF007,Existing,PPO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350008-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Gold 2500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350008,"Voyager Gold 2500",60597ID035,,IDN005,IDS006,IDF007,Existing,PPO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350008-03,"Limited Cost Sharing Plan Variation",,0.817277417,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,000 ","$6000 per person | $12000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",10.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",10.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$20 ","$0 ",100%,"Not Applicable",No,"Voyager Gold 2500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350009,"Voyager Bronze 9400",60597ID035,,IDN005,IDS006,IDF008,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350009-01,"Standard Bronze On Exchange Plan",,0.646025817,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$9,400 ","$0 ","$0 ","$60 ","$4,300 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Bronze 9400","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350009,"Voyager Bronze 9400",60597ID035,,IDN005,IDS006,IDF008,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350009-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Bronze 9400","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350009,"Voyager Bronze 9400",60597ID035,,IDN005,IDS006,IDF008,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350009-03,"Limited Cost Sharing Plan Variation",,0.646025817,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Bronze 9400","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350010,"Voyager Gold 500",60597ID035,,IDN005,IDS006,IDF018,New,PPO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350010-01,"Standard Gold On Exchange Plan",,0.816087463,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,500 ","$8500 per person | $17000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1000 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$500 ","$10 ","$3,600 ","$60 ","$500 ","$400 ","$1,100 ","$20 ",100%,"Not Applicable",No,"Voyager Gold 500","$500 ","$200 ","$600 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350010,"Voyager Gold 500",60597ID035,,IDN005,IDS006,IDF018,New,PPO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350010-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Gold 500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0350010,"Voyager Gold 500",60597ID035,,IDN005,IDS006,IDF018,New,PPO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0350010-03,"Limited Cost Sharing Plan Variation",,0.816087463,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,500 ","$8500 per person | $17000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1000 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Voyager Gold 500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360002,"Navigator Bronze HSA 7500",60597ID036,,IDN006,IDS002,IDF004,Existing,HMO,"Expanded Bronze",No,Both,No,No,,,Yes,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360002-01,"Standard Bronze On Exchange Plan",,0.639604829,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Bronze HSA 7500","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360002,"Navigator Bronze HSA 7500",60597ID036,,IDN006,IDS002,IDF004,Existing,HMO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360002-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Bronze 7500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360002,"Navigator Bronze HSA 7500",60597ID036,,IDN006,IDS002,IDF004,Existing,HMO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360002-03,"Limited Cost Sharing Plan Variation",,0.639604829,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Bronze 7500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360003,"Navigator Silver HSA 3500",60597ID036,,IDN006,IDS002,IDF001,Existing,HMO,Silver,No,Both,No,No,,,Yes,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360003-01,"Standard Silver On Exchange Plan",,0.709375341,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,700 ","$6700 per person | $13400 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,500 ","$3500 per person | $7000 per group",25.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$0 ","$2,300 ","$60 ","$3,500 ","$0 ","$500 ","$20 ",100%,"Not Applicable",No,"Navigator Silver HSA 3500","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360003,"Navigator Silver HSA 3500",60597ID036,,IDN006,IDS002,IDF001,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360003-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Silver 3500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360003,"Navigator Silver HSA 3500",60597ID036,,IDN006,IDS002,IDF001,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360003-03,"Limited Cost Sharing Plan Variation",,0.709375341,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,700 ","$6700 per person | $13400 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,500 ","$3500 per person | $7000 per group",25.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Silver 3500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360003,"Navigator Silver HSA 3500",60597ID036,,IDN006,IDS002,IDF001,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360003-04,"73% AV Level Silver Plan",,0.738742155,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,400 ","$6400 per person | $12800 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$2,400 ","$2400 per person | $4800 per group",25.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$2,400 ","$0 ","$2,500 ","$60 ","$2,400 ","$0 ","$800 ","$20 ",100%,"Not Applicable",No,"Navigator Silver 3500","$2,400 ","$0 ","$100 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360003,"Navigator Silver HSA 3500",60597ID036,,IDN006,IDS002,IDF001,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360003-05,"87% AV Level Silver Plan",,0.876329941,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,800 ","$1800 per person | $3600 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$1,100 ","$1100 per person | $2200 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$1,100 ","$0 ","$700 ","$60 ","$1,100 ","$0 ","$700 ","$20 ",100%,"Not Applicable",No,"Navigator Silver 3500","$1,100 ","$0 ","$300 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360003,"Navigator Silver HSA 3500",60597ID036,,IDN006,IDS002,IDF001,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360003-06,"94% AV Level Silver Plan",,0.943965196,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$600 ","$600 per person | $1200 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$400 ","$400 per person | $800 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$400 ","$0 ","$200 ","$60 ","$400 ","$0 ","$200 ","$20 ",100%,"Not Applicable",No,"Navigator Silver 3500","$400 ","$0 ","$200 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360008,"Navigator Silver 3600",60597ID036,,IDN006,IDS002,IDF006,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360008-01,"Standard Silver On Exchange Plan",,0.717828581,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$3,600 ","$3600 per person | $7200 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$3,600 ","$0 ","$3,600 ","$60 ","$3,600 ","$300 ","$400 ","$20 ",100%,"Not Applicable",No,"Navigator Silver 3600","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360008,"Navigator Silver 3600",60597ID036,,IDN006,IDS002,IDF006,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360008-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Silver 3600","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360008,"Navigator Silver 3600",60597ID036,,IDN006,IDS002,IDF006,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360008-03,"Limited Cost Sharing Plan Variation",,0.717828581,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$3,600 ","$3600 per person | $7200 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Silver 3600","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360008,"Navigator Silver 3600",60597ID036,,IDN006,IDS002,IDF006,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360008-04,"73% AV Level Silver Plan",,0.739544847,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$3,300 ","$3300 per person | $6600 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$3,300 ","$10 ","$3,700 ","$60 ","$1,200 ","$1,200 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Silver 3600","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360008,"Navigator Silver 3600",60597ID036,,IDN006,IDS002,IDF006,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360008-05,"87% AV Level Silver Plan",,0.876923861,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,200 ","$2200 per person | $4400 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$1,100 ","$1100 per person | $2200 per group",25.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$1,100 ","$0 ","$1,100 ","$60 ","$1,100 ","$1,100 ","$20 ","$20 ",100%,"Not Applicable",No,"Navigator Silver 3600","$1,100 ","$10 ","$400 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360008,"Navigator Silver 3600",60597ID036,,IDN006,IDS002,IDF006,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360008-06,"94% AV Level Silver Plan",,0.943846847,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$650 ","$650 per person | $1300 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$400 ","$0 ","$300 ","$60 ","$400 ","$200 ","$30 ","$20 ",100%,"Not Applicable",No,"Navigator Silver 3600","$400 ","$0 ","$300 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360009,"Navigator Gold 2500",60597ID036,,IDN006,IDS002,IDF007,Existing,HMO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360009-01,"Standard Gold On Exchange Plan",,0.817277417,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,000 ","$6000 per person | $12000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",10.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",10.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$2,500 ","$10 ","$1,000 ","$60 ","$900 ","$1,200 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Gold 2500","$2,500 ","$200 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360009,"Navigator Gold 2500",60597ID036,,IDN006,IDS002,IDF007,Existing,HMO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360009-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Gold 2500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360009,"Navigator Gold 2500",60597ID036,,IDN006,IDS002,IDF007,Existing,HMO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360009-03,"Limited Cost Sharing Plan Variation",,0.817277417,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,000 ","$6000 per person | $12000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",10.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",10.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$20 ","$0 ",100%,"Not Applicable",No,"Navigator Gold 2500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360010,"Navigator Bronze 6000",60597ID036,,IDN006,IDS002,IDF005,Existing,HMO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360010-01,"Standard Bronze On Exchange Plan",,0.649236095,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,000 ","$6000 per person | $12000 per group",50.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$6,000 ","$0 ","$3,000 ","$60 ","$4,300 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Bronze 6000","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360010,"Navigator Bronze 6000",60597ID036,,IDN006,IDS002,IDF005,Existing,HMO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360010-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Bronze 6000","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360010,"Navigator Bronze 6000",60597ID036,,IDN006,IDS002,IDF005,Existing,HMO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360010-03,"Limited Cost Sharing Plan Variation",,0.649236095,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,000 ","$6000 per person | $12000 per group",50.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Bronze 6000","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360011,"Navigator Bronze 9400",60597ID036,,IDN006,IDS002,IDF008,Existing,HMO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360011-01,"Standard Bronze On Exchange Plan",,0.646025817,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$9,400 ","$0 ","$0 ","$60 ","$4,300 ","$400 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Bronze 9400","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360011,"Navigator Bronze 9400",60597ID036,,IDN006,IDS002,IDF008,Existing,HMO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360011-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Bronze 9400","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360011,"Navigator Bronze 9400",60597ID036,,IDN006,IDS002,IDF008,Existing,HMO,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360011-03,"Limited Cost Sharing Plan Variation",,0.646025817,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Bronze 9400","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360012,"Navigator Gold 500",60597ID036,,IDN006,IDS002,IDF018,New,HMO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360012-01,"Standard Gold On Exchange Plan",,0.816087463,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,500 ","$8500 per person | $17000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1000 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$500 ","$10 ","$3,600 ","$60 ","$500 ","$400 ","$1,100 ","$20 ",100%,"Not Applicable",No,"Navigator Gold 500","$500 ","$200 ","$600 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360012,"Navigator Gold 500",60597ID036,,IDN006,IDS002,IDF018,New,HMO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360012-02,"Zero Cost Sharing Plan Variation",,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Gold 500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,No,,60597ID0360012,"Navigator Gold 500",60597ID036,,IDN006,IDS002,IDF018,New,HMO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Emergency Care Only",Yes,,,,,60597ID0360012-03,"Limited Cost Sharing Plan Variation",,0.816087463,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,500 ","$8500 per person | $17000 per group",,,"$85,500 ","$85500 per person | $171000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1000 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$0 ","$60 ","$0 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Navigator Gold 500","$0 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0380001,"Voyager Silver 4500",60597ID038,,IDN001,IDS001,IDF009,Existing,PPO,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0380001-01,"Standard Silver On Exchange Plan",71.80%,0.718389509,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",35.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",35.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$4,500 ","$10 ","$2,400 ","$60 ","$900 ","$1,500 ","$0 ","$20 ",,,Yes,"Voyager Silver 4500","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0380002,"Voyager Silver 5500",60597ID038,,IDN001,IDS001,IDF010,Existing,PPO,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0380002-01,"Standard Silver On Exchange Plan",71.68%,0.717375632,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,100 ","$60 ","$900 ","$1,500 ","$0 ","$20 ",,,Yes,"Voyager Silver 5500","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0380003,"Voyager Silver 6500",60597ID038,,IDN001,IDS001,IDF010,Existing,PPO,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0380003-01,"Standard Silver On Exchange Plan",71.46%,0.714828838,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$6500 per person | $13000 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$6,500 ","$10 ","$1,800 ","$60 ","$900 ","$1,500 ","$0 ","$20 ",,,Yes,"Voyager Silver 6500","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0380004,"Voyager Gold 1000",60597ID038,,IDN001,IDS001,IDF011,Existing,PPO,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0380004-01,"Standard Gold On Exchange Plan",81.50%,0.802422335,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,600 ","$6600 per person | $13200 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | $2000 per group",25.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$1,000 ","$10 ","$2,900 ","$60 ","$900 ","$1,100 ","$0 ","$20 ",,,Yes,"Voyager Gold 1000","$1,000 ","$300 ","$300 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0380005,"Voyager Gold 2000",60597ID038,,IDN001,IDS001,IDF011,Existing,PPO,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0380005-01,"Standard Gold On Exchange Plan",80.84%,0.809564857,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,500 ","$5500 per person | $11000 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",25.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",75.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,600 ","$60 ","$900 ","$1,100 ","$0 ","$20 ",,,Yes,"Voyager Gold 2000","$2,000 ","$300 ","$20 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0380006,"Voyager Bronze 6800",60597ID038,,IDN001,IDS001,IDF012,Existing,PPO,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0380006-01,"Standard Bronze On Exchange Plan",64.97%,0.649743933,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,600 ","$8600 per person | $17200 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,800 ","$6800 per person | $13600 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$6,800 ","$0 ","$1,800 ","$60 ","$4,700 ","$300 ","$0 ","$20 ",,,Yes,"Voyager Bronze 6800","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0380007,"Voyager Silver 3000",60597ID038,,IDN001,IDS001,IDF013,Existing,PPO,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0380007-01,"Standard Silver On Exchange Plan",71.53%,0.715891316,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$3,000 ","$10 ","$3,800 ","$60 ","$900 ","$1,900 ","$0 ","$20 ",,,Yes,"Voyager Silver 3000","$2,100 ","$500 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0380008,"Voyager Bronze 9400",60597ID038,,IDN001,IDS001,IDF014,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0380008-01,"Standard Bronze On Exchange Plan",,0.646025817,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$9,400 ","$0 ","$0 ","$60 ","$4,300 ","$400 ","$0 ","$20 ",,,Yes,"Voyager Bronze 9400","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0380010,"Voyager Platinum 500",60597ID038,,IDN001,IDS001,IDF017,New,PPO,Platinum,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0380010-01,"Standard Platinum On Exchange Plan",89.32%,0.896166238,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,000 ","$3000 per person | $6000 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1000 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$500 ","$10 ","$2,400 ","$60 ","$500 ","$400 ","$80 ","$20 ",,,Yes,"Voyager Platinum 500","$500 ","$70 ","$400 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0400001,"Navigator Bronze 6800",60597ID040,,IDN002,IDS003,IDF012,Existing,HMO,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0400001-01,"Standard Bronze On Exchange Plan",64.97%,0.649743933,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,600 ","$8600 per person | $17200 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,800 ","$6800 per person | $13600 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$6,800 ","$0 ","$1,800 ","$60 ","$4,700 ","$300 ","$0 ","$20 ",,,Yes,"Navigator Bronze 6800","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0400002,"Navigator Silver 3000",60597ID040,,IDN002,IDS003,IDF013,Existing,HMO,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0400002-01,"Standard Silver On Exchange Plan",71.53%,0.715891316,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$3,000 ","$10 ","$3,800 ","$60 ","$900 ","$1,900 ","$0 ","$20 ",,,Yes,"Navigator Silver 3000","$2,100 ","$500 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0400003,"Navigator Bronze 9400",60597ID040,,IDN002,IDS003,IDF014,Existing,HMO,"Expanded Bronze",No,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0400003-01,"Standard Bronze On Exchange Plan",,0.646025817,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$9,400 ","$0 ","$0 ","$60 ","$4,300 ","$400 ","$0 ","$20 ",,,Yes,"Navigator Bronze 9400","$2,800 ","$10 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0400005,"Navigator Platinum 500",60597ID040,,IDN002,IDS003,IDF017,New,HMO,Platinum,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0400005-01,"Standard Platinum On Exchange Plan",89.32%,0.896166238,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,000 ","$3000 per person | $6000 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1000 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$500 ","$10 ","$2,400 ","$60 ","$500 ","$400 ","$80 ","$20 ",,,Yes,"Navigator Platinum 500","$500 ","$70 ","$400 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0400006,"Navigator Silver 4500",60597ID040,,IDN002,IDS003,IDF009,Existing,HMO,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0400006-01,"Standard Silver On Exchange Plan",71.80%,0.718389509,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",35.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",35.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$4,500 ","$10 ","$2,400 ","$60 ","$900 ","$1,500 ","$0 ","$20 ",,,Yes,"Navigator Silver 4500","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0400007,"Navigator Silver 5500",60597ID040,,IDN002,IDS003,IDF010,Existing,HMO,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0400007-01,"Standard Silver On Exchange Plan",71.68%,0.717375632,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,400 ","$9400 per person | $18800 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,100 ","$60 ","$900 ","$1,500 ","$0 ","$20 ",,,Yes,"Navigator Silver 5500","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0400008,"Navigator Silver 6500",60597ID040,,IDN002,IDS003,IDF010,Existing,HMO,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0400008-01,"Standard Silver On Exchange Plan",71.46%,0.714828838,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$6500 per person | $13000 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$6,500 ","$10 ","$1,800 ","$60 ","$900 ","$1,500 ","$0 ","$20 ",,,Yes,"Navigator Silver 6500","$2,100 ","$400 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0400009,"Navigator Gold 1000",60597ID040,,IDN002,IDS003,IDF011,Existing,HMO,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0400009-01,"Standard Gold On Exchange Plan",81.50%,0.816959957,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,600 ","$6600 per person | $13200 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | $2000 per group",25.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$1,000 ","$10 ","$2,900 ","$60 ","$900 ","$1,100 ","$0 ","$20 ",,,Yes,"Navigator Gold 1000","$1,000 ","$300 ","$300 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0400010,"Navigator Gold 2000",60597ID040,,IDN002,IDS003,IDF011,Existing,HMO,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0400010-01,"Standard Gold On Exchange Plan",80.84%,0.809564857,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,500 ","$5500 per person | $11000 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",25.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",25.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,600 ","$60 ","$900 ","$1,100 ","$0 ","$20 ",,,Yes,"Navigator Gold 2000","$2,000 ","$300 ","$20 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,Yes,,60597ID0410001,"Dental PPO 0-20-50 1000",60597ID041,,IDN007,IDS004,,Existing,PPO,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Non-participating providers",Yes,,,,,60597ID0410001-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"$50 ","$50 per person | $150 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Dental PPO 0-20-50 1000",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,Yes,,60597ID0410002,"Kids Dental PPO 0-20-50",60597ID041,,IDN007,IDS004,,Existing,PPO,High,,Both,,,,,,,,"Allows Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Non-participating providers",Yes,,,,,60597ID0410002-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"$50 ","$50 per person | $150 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Kids Dental PPO 0-20-50",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,Individual,Yes,,60597ID0410003,"Dental PPO 0-20-50 1500",60597ID041,,IDN007,IDS004,,Existing,PPO,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Non-participating providers",Yes,,,,,60597ID0410003-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"$50 ","$50 per person | $150 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Dental PPO 0-20-50 1500",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,60597ID0420001,"Dental PPO Core",60597ID042,,IDN003,IDS005,,Existing,PPO,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Non-participating providers",Yes,,,,,60597ID0420001-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"$50 ","$50 per person | $150 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Yes,"Dental PPO Core",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,60597ID0420002,"Dental PPO 0-20-50 750",60597ID042,,IDN003,IDS005,,Existing,PPO,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Non-participating providers",Yes,,,,,60597ID0420002-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"$50 ","$50 per person | $150 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Yes,"Dental PPO 0-20-50 750",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,60597ID0420003,"Dental PPO 0-20-50 1000",60597ID042,,IDN003,IDS005,,Existing,PPO,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Non-participating providers",Yes,,,,,60597ID0420003-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"$50 ","$50 per person | $150 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Yes,"Dental PPO 0-20-50 1000",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,60597ID0420004,"Dental PPO 0-20-50 1500",60597ID042,,IDN003,IDS005,,Existing,PPO,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Non-participating providers",Yes,,,,,60597ID0420004-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"$50 ","$50 per person | $150 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Yes,"Dental PPO 0-20-50 1500",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,60597ID0420005,"Dental PPO Plus 0-20-50 1000",60597ID042,,IDN003,IDS005,,Existing,PPO,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Non-participating providers",Yes,,,,,60597ID0420005-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"$50 ","$50 per person | $150 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Yes,"Dental PPO Plus 0-20-50 1000",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,60597ID0420006,"Dental PPO Plus 0-20-50 1500",60597ID042,,IDN003,IDS005,,Existing,PPO,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Non-participating providers",Yes,,,,,60597ID0420006-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"$50 ","$50 per person | $150 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Yes,"Dental PPO Plus 0-20-50 1500",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,60597ID0420007,"Kids Dental PPO 0-20-50",60597ID042,,IDN003,IDS005,,Existing,PPO,High,,Both,,,,,,,,"Allows Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Non-participating providers",Yes,,,,,60597ID0420007-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"$50 ","$50 per person | $150 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Yes,"Kids Dental PPO 0-20-50",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,60597ID0420008,"Kids Dental PPO 20-40-50",60597ID042,,IDN003,IDS005,,Existing,PPO,Low,,Both,,,,,,,,"Allows Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Non-participating providers",Yes,,,,,60597ID0420008-01,"Standard Low On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"$50 ","$50 per person | $150 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Yes,"Kids Dental PPO 20-40-50",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,60597ID0430001,"Dental Choice 0-20-50 50-1000",60597ID043,,IDN004,IDS005,,Existing,Indemnity,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"This plan covers eligible services when performed by an eligible provider.",Yes,,,,,60597ID0430001-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"Not Applicable","per person not applicable | per group not applicable","$50 ","$50 per person | $150 per group",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Yes,"Dental Choice 0-20-50 50-1000",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,60597ID0430002,"Dental Choice Plus 0-20-50 25-1000",60597ID043,,IDN004,IDS005,,Existing,Indemnity,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"This plan covers eligible services when performed by an eligible provider.",Yes,,,,,60597ID0430002-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"Not Applicable","per person not applicable | per group not applicable","$25 ","$25 per person | $75 per group",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Yes,"Dental Choice Plus 0-20-50 25-1000",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,60597ID0430003,"Dental Choice Plus 0-20-50 50-1000",60597ID043,,IDN004,IDS005,,Existing,Indemnity,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"This plan covers eligible services when performed by an eligible provider.",Yes,,,,,60597ID0430003-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"Not Applicable","per person not applicable | per group not applicable","$50 ","$50 per person | $150 per group",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Yes,"Dental Choice Plus 0-20-50 50-1000",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,60597ID0430004,"Dental Choice Plus 0-20-50 25-1500",60597ID043,,IDN004,IDS005,,Existing,Indemnity,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"This plan covers eligible services when performed by an eligible provider.",Yes,,,,,60597ID0430004-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"Not Applicable","per person not applicable | per group not applicable","$25 ","$25 per person | $75 per group",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Yes,"Dental Choice Plus 0-20-50 25-1500",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,60597ID0430005,"Dental Choice Plus 0-20-50 50-1500",60597ID043,,IDN004,IDS005,,Existing,Indemnity,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"This plan covers eligible services when performed by an eligible provider.",Yes,,,,,60597ID0430005-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"Not Applicable","per person not applicable | per group not applicable","$50 ","$50 per person | $150 per group",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Yes,"Dental Choice Plus 0-20-50 50-1500",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,60597ID0430006,"Dental Choice 0-20-50 50-1500",60597ID043,,IDN004,IDS005,,Existing,Indemnity,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"This plan covers eligible services when performed by an eligible provider.",Yes,,,,,60597ID0430006-01,"Standard High On Exchange Plan",,,,,No,100%,,"Not Applicable","per person not applicable | per group not applicable",,,"Not Applicable","per person not applicable | per group not applicable","$400 ","$400 per person | $800 per group",,,,,,,,,,,,,,,,,"Not Applicable","per person not applicable | per group not applicable",,,,,"Not Applicable","per person not applicable | per group not applicable","$50 ","$50 per person | $150 per group",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Yes,"Dental Choice 0-20-50 50-1500",,,,
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0440001,"Navigator Bronze HSA 7500",60597ID044,,IDN002,IDS003,IDF015,Existing,HMO,"Expanded Bronze",No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0440001-01,"Standard Bronze On Exchange Plan",,0.639604829,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",,,Yes,"Navigator Bronze HSA 7500","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0440003,"Navigator Silver HSA 5100",60597ID044,,IDN002,IDS003,IDF015,Existing,HMO,Silver,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0440003-01,"Standard Silver On Exchange Plan",,0.719211218,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,100 ","$5100 per person | $10200 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,100 ","$5100 per person | $10200 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$5,100 ","$0 ","$0 ","$60 ","$5,100 ","$0 ","$0 ","$20 ",,,Yes,"Navigator Silver HSA 5100","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0440004,"Navigator Silver HSA 3500",60597ID044,,IDN002,IDS003,IDF016,Existing,HMO,Silver,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0440004-01,"Standard Silver On Exchange Plan",,0.707486604,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,500 ","$3500 per person | $7000 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$0 ","$1,800 ","$60 ","$3,500 ","$0 ","$400 ","$20 ",,,Yes,"Navigator Silver HSA 3500","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0440005,"Navigator Gold HSA 3200",60597ID044,,IDN002,IDS003,IDF015,Existing,HMO,Gold,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0440005-01,"Standard Gold On Exchange Plan",,0.800875982,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,200 ","$3200 per person | $6400 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,200 ","$3200 per person | $6400 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$3,200 ","$0 ","$0 ","$60 ","$3,200 ","$0 ","$0 ","$20 ",,,Yes,"Navigator Gold HSA 3200","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0450001,"Voyager Bronze HSA 7500",60597ID045,,IDN001,IDS001,IDF015,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0450001-01,"Standard Bronze On Exchange Plan",,0.639604829,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",,,Yes,"Voyager Bronze HSA 7500","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0450003,"Voyager Silver HSA 5100",60597ID045,,IDN001,IDS001,IDF015,Existing,PPO,Silver,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0450003-01,"Standard Silver On Exchange Plan",,0.719211218,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,100 ","$5100 per person | $10200 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,100 ","$5100 per person | $10200 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$5,100 ","$0 ","$0 ","$60 ","$5,100 ","$0 ","$0 ","$20 ",,,Yes,"Voyager Silver HSA 5100","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0450004,"Voyager Silver HSA 3500",60597ID045,,IDN001,IDS001,IDF016,Existing,PPO,Silver,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0450004-01,"Standard Silver On Exchange Plan",,0.707486604,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,500 ","$3500 per person | $7000 per group",20.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$0 ","$1,800 ","$60 ","$3,500 ","$0 ","$400 ","$20 ",,,Yes,"Voyager Silver HSA 3500","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,60597,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,60597ID0450005,"Voyager Gold HSA 3200",60597ID045,,IDN001,IDS001,IDF015,Existing,PPO,Gold,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,,,,,,,,1/1/2024,,Yes,"Emergency Care Only",Yes,"Out-of-network providers",Yes,,,,,60597ID0450005-01,"Standard Gold On Exchange Plan",,0.800875982,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,200 ","$3200 per person | $6400 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,200 ","$3200 per person | $6400 per group",0.00%,,,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable","$3,200 ","$0 ","$0 ","$60 ","$3,200 ","$0 ","$0 ","$20 ",,,Yes,"Voyager Gold HSA 3200","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,Yes,,61589ID1710001,"Dental Choice Plus",61589ID171,,IDN001,IDS002,,Existing,PPO,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID1710001-01,"Standard High On Exchange Plan",,,,,No,100%,,"$375 ","$375 per person | $750 per group",,,"$10,000 ","$10000 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"$25 ","$25 per person | per group not applicable",,,,,"$100 ","$100 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Dental Choice Plus",,,,
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,Yes,,61589ID1720001,"Dental Choice",61589ID172,,IDN001,IDS002,,Existing,PPO,Low,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,100.00%,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID1720001-01,"Standard Low On Exchange Plan",,,,,No,100%,,"$375 ","$375 per person | $750 per group",,,"$10,000 ","$10000 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"$25 ","$25 per person | per group not applicable",,,,,"$100 ","$100 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Dental Choice",,,,
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,61589ID1920001,"Group Dental Choice Plus",61589ID192,,IDN001,IDS002,,Existing,PPO,High,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID1920001-01,"Standard High On Exchange Plan",,,,,No,100%,,"$375 ","$375 per person | $750 per group",,,"$10,000 ","$10000 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"$50 ","$50 per person | per group not applicable",,,,,"$100 ","$100 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Group Dental Choice Plus",,,,
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",Yes,,61589ID1930001,"Group Dental Choice",61589ID193,,IDN001,IDS002,,Existing,PPO,Low,,Both,,,,,,,,"Allows Adult and Child-Only",,No,,,"Guaranteed Rate",,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID1930001-01,"Standard Low On Exchange Plan",,,,,No,100%,,"$375 ","$375 per person | $750 per group",,,"$10,000 ","$10000 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,"$75 ","$75 per person | per group not applicable",,,,,"$100 ","$100 per person | per group not applicable","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,No,"Group Dental Choice",,,,
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2340003,"Bronze HSA 7150 Choice",61589ID234,,IDN002,IDS001,IDF011,Existing,PPO,"Expanded Bronze",No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2340003-01,"Standard Bronze On Exchange Plan",,0.64718734,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,150 ","$7150 per person | $14300 per group",,,"$14,300 ","$14300 per person | $28600 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,150 ","$7150 per person | $14300 per group",0.00%,,,,"$14,300 ","$14300 per person | $28600 per group","Not Applicable","per person not applicable | per group not applicable","$7,150 ","$0 ","$0 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",,,No,"Bronze HSA 7150 Choice","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2340007,"Silver 4500 Choice",61589ID234,,IDN002,IDS001,IDF007,Existing,PPO,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2340007-01,"Standard Silver On Exchange Plan",71.76%,0.712348979,No,Yes,Yes,38%,62%,,,,,,,,,,,,,,,,,"$8,800 ","$8800 per person | $17600 per group","$8,800 ","$8800 per person | $17600 per group","$17,600 ","$17600 per person | $35200 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,"$4,500 ","$4500 per person | $9000 per group",30.00%,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,"Not Applicable","per person not applicable | per group not applicable",30.00%,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$10 ","$2,420 ","$60 ","$120 ","$1,190 ","$0 ","$20 ",,,No,"Silver 4500 Choice","$2,450 ","$130 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2340008,"Silver HSA 5300 Choice",61589ID234,,IDN002,IDS001,IDF011,Existing,PPO,Silver,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2340008-01,"Standard Silver On Exchange Plan",,0.713281073,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,300 ","$5300 per person | $10600 per group",,,"$10,600 ","$10600 per person | $21200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,300 ","$5300 per person | $10600 per group",0.00%,,,,"$10,600 ","$10600 per person | $21200 per group","Not Applicable","per person not applicable | per group not applicable","$5,300 ","$0 ","$0 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",,,No,"Silver HSA 5300 Choice","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2340009,"Silver HSA 3200 Choice",61589ID234,,IDN002,IDS001,IDF012,Existing,PPO,Silver,Yes,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2340009-01,"Standard Silver On Exchange Plan",71.43%,0.719605817,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,600 ","$6600 per person | $13200 per group",,,"$13,200 ","$13200 per person | $26400 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,200 ","$3200 per person | $6400 per group",30.00%,,,,"$6,400 ","$6400 per person | $12800 per group","Not Applicable","per person not applicable | per group not applicable","$3,200 ","$0 ","$2,810 ","$60 ","$3,200 ","$315 ","$340 ","$20 ",,,No,"Silver HSA 3200 Choice","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2340010,"Gold 900 Choice",61589ID234,,IDN002,IDS001,IDF007,Existing,PPO,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2340010-01,"Standard Gold On Exchange Plan",78.73%,0.794839696,No,Yes,Yes,38%,62%,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group","$9,450 ","$9450 per person | $18900 per group","$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$900 ","$900 per person | $1800 per group",20.00%,"$900 ","$900 per person | $1800 per group",20.00%,"$1,800 ","$1800 per person | $3600 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,"Not Applicable","per person not applicable | per group not applicable",20.00%,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$900 ","$10 ","$2,330 ","$60 ","$120 ","$1,070 ","$0 ","$20 ",,,No,"Gold 900 Choice","$900 ","$450 ","$240 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2340013,"Gold 2000 Choice",61589ID234,,IDN002,IDS001,IDF007,Existing,PPO,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2340013-01,"Standard Gold On Exchange Plan",81.55%,0.786432422,No,Yes,Yes,38%,62%,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group","$7,500 ","$7500 per person | $15000 per group","$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,"$2,000 ","$2000 per person | $4000 per group",20.00%,"$4,000 ","$4000 per person | $8000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,"Not Applicable","per person not applicable | per group not applicable",20.00%,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$120 ","$1,030 ","$0 ","$20 ",,,No,"Gold 2000 Choice","$2,000 ","$420 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2340015,"Bronze 6500 Choice ",61589ID234,,IDN002,IDS001,IDF010,Existing,PPO,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2340015-01,"Standard Bronze On Exchange Plan",64.14%,0.636881025,Yes,Yes,Yes,38%,62%,,,,,,,,,,,,,,,,,"$9,200 ","$9200 per person | $18400 per group","$9,200 ","$9200 per person | $18400 per group","$18,400 ","$18400 per person | $36800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",40.00%,"$6,500 ","$6500 per person | $13000 per group",40.00%,"$13,000 ","$13000 per person | $26000 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$10 ","$2,430 ","$60 ","$3,550 ","$590 ","$0 ","$20 ",,,No,"Bronze 6500 Choice ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2340016,"Silver 5500 Choice",61589ID234,,IDN002,IDS001,IDF007,Existing,PPO,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2340016-01,"Standard Silver On Exchange Plan",71.84%,0.711596576,No,Yes,Yes,38%,62%,,,,,,,,,,,,,,,,,"$8,550 ","$8550 per person | $17100 per group","$8,550 ","$8550 per person | $17100 per group","$17,100 ","$17100 per person | $34200 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",30.00%,"$5,500 ","$5500 per person | $11000 per group",30.00%,"$11,000 ","$11000 per person | $22000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,"Not Applicable","per person not applicable | per group not applicable",30.00%,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,120 ","$60 ","$120 ","$1,110 ","$0 ","$20 ",,,No,"Silver 5500 Choice","$2,450 ","$100 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2340018,"Bronze 7500 Choice",61589ID234,,IDN002,IDS001,IDF010,Existing,PPO,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2340018-01,"Standard Bronze On Exchange Plan",63.31%,0.632432595,Yes,Yes,Yes,38%,62%,,,,,,,,,,,,,,,,,"$9,300 ","$9300 per person | $18600 per group","$9,300 ","$9300 per person | $18600 per group","$18,600 ","$18600 per person | $37200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,"$7,500 ","$7500 per person | $15000 per group",40.00%,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$10 ","$1,790 ","$60 ","$3,550 ","$530 ","$0 ","$20 ",,,No,"Bronze 7500 Choice","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2340019,"Silver 6500 Choice",61589ID234,,IDN002,IDS001,IDF007,Existing,PPO,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2340019-01,"Standard Silver On Exchange Plan",71.83%,0.713095543,No,Yes,Yes,38%,62%,,,,,,,,,,,,,,,,,"$7,450 ","$7450 per person | $14900 per group","$7,450 ","$7450 per person | $14900 per group","$14,900 ","$14900 per person | $29800 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$6500 per person | $13000 per group",30.00%,"$6,500 ","$6500 per person | $13000 per group",30.00%,"$13,000 ","$13000 per person | $26000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,"Not Applicable","per person not applicable | per group not applicable",30.00%,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$6,500 ","$10 ","$940 ","$60 ","$280 ","$950 ","$0 ","$20 ",,,No,"Silver 6500 Choice","$2,450 ","$130 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2340020,"Bronze 9000 Choice Deductible-First",61589ID234,,IDN002,IDS001,IDF009,Existing,PPO,Bronze,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2340020-01,"Standard Bronze On Exchange Plan",61.49%,0.610350587,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",0.00%,,,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable","$9,000 ","$0 ","$0 ","$60 ","$4,420 ","$370 ","$0 ","$20 ",,,No,"Bronze 9000 Choice Deductible-First","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2340021,"Gold HSA 3700 Choice",61589ID234,,IDN002,IDS001,IDF011,Existing,PPO,Gold,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2340021-01,"Standard Gold On Exchange Plan",,0.781982573,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,700 ","$3700 per person | $7400 per group",,,"$7,400 ","$7400 per person | $14800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,700 ","$3700 per person | $7400 per group",0.00%,,,,"$7,400 ","$7400 per person | $14800 per group","Not Applicable","per person not applicable | per group not applicable","$3,700 ","$0 ","$0 ","$60 ","$3,700 ","$0 ","$0 ","$20 ",,,No,"Gold HSA 3700 Choice","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2340022,"Gold 3000 Choice",61589ID234,,IDN002,IDS001,IDF007,Existing,PPO,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2340022-01,"Standard Gold On Exchange Plan",78.66%,0.779470081,No,Yes,Yes,38%,62%,,,,,,,,,,,,,,,,,"$6,200 ","$6200 per person | $12400 per group","$6,200 ","$6200 per person | $12400 per group","$12,400 ","$12400 per person | $24800 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",20.00%,"$3,000 ","$3000 per person | $6000 per group",20.00%,"$6,000 ","$6000 per person | $12000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,"Not Applicable","per person not applicable | per group not applicable",20.00%,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$10 ","$1,910 ","$60 ","$120 ","$990 ","$0 ","$20 ",,,No,"Gold 3000 Choice","$2,450 ","$70 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2340023,"Silver Copay 2000 Choice",61589ID234,,IDN002,IDS001,IDF008,New,PPO,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2340023-01,"Standard Silver On Exchange Plan",69.71%,0.720043461,Yes,Yes,Yes,38%,62%,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group","$9,450 ","$9450 per person | $18900 per group","$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$2,000 ","$2000 per person | $4000 per group",50.00%,"$2,000 ","$2000 per person | $4000 per group",50.00%,"$4,000 ","$4000 per person | $8000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$1,360 ","$4,540 ","$60 ","$2,000 ","$890 ","$640 ","$20 ",,,No,"Silver Copay 2000 Choice","$1,235 ","$1,140 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350010,"Silver 4500 PQA Connect",61589ID235,,IDN006,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350010-01,"Standard Silver On Exchange Plan",71.55%,0.708806248,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,800 ","$8800 per person | $17600 per group",,,"$17,600 ","$17600 per person | $35200 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$10 ","$2,420 ","$60 ","$120 ","$1,310 ","$0 ","$20 ",,,No,"Silver 4500 PQA Connect","$2,450 ","$190 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350014,"Silver 4500 SAHA Connect",61589ID235,,IDN009,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350014-01,"Standard Silver On Exchange Plan",71.55%,0.708806248,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,800 ","$8800 per person | $17600 per group",,,"$17,600 ","$17600 per person | $35200 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$10 ","$2,420 ","$60 ","$120 ","$1,310 ","$0 ","$20 ",,,No,"Silver 4500 SAHA Connect","$2,450 ","$190 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350018,"Silver 4500 Point",61589ID235,,IDN003,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350018-01,"Standard Silver On Exchange Plan",71.55%,0.708806248,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,800 ","$8800 per person | $17600 per group",,,"$17,600 ","$17600 per person | $35200 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$10 ","$2,420 ","$60 ","$120 ","$1,310 ","$0 ","$20 ",,,No,"Silver 4500 Point","$2,450 ","$190 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350020,"Gold 2000 PQA Connect ",61589ID235,,IDN006,IDS001,IDF007,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350020-01,"Standard Gold On Exchange Plan",81.19%,0.779749197,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$4,000 ","$4000 per person | $8000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$120 ","$1,150 ","$0 ","$20 ",,,No,"Gold 2000 PQA Connect ","$2,000 ","$480 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350021,"Gold 900 PQA Connect",61589ID235,,IDN006,IDS001,IDF007,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350021-01,"Standard Gold On Exchange Plan",78.19%,0.790505779,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$900 ","$900 per person | $1800 per group",20.00%,,,,"$1,800 ","$1800 per person | $3600 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$900 ","$10 ","$2,330 ","$60 ","$120 ","$1,190 ","$0 ","$20 ",,,No,"Gold 900 PQA Connect","$900 ","$510 ","$240 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350024,"Gold 900 SAHA Connect",61589ID235,,IDN009,IDS001,IDF007,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350024-01,"Standard Gold On Exchange Plan",78.19%,0.790505779,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$900 ","$900 per person | $1800 per group",20.00%,,,,"$1,800 ","$1800 per person | $3600 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$900 ","$10 ","$2,330 ","$60 ","$120 ","$1,190 ","$0 ","$20 ",,,No,"Gold 900 SAHA Connect","$900 ","$510 ","$240 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350026,"Gold 2000 SAHA Connect ",61589ID235,,IDN009,IDS001,IDF007,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350026-01,"Standard Gold On Exchange Plan",81.19%,0.779749197,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$4,000 ","$4000 per person | $8000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$120 ","$1,150 ","$0 ","$20 ",,,No,"Gold 2000 SAHA Connect ","$2,000 ","$480 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350029,"Gold 900 Point",61589ID235,,IDN003,IDS001,IDF007,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350029-01,"Standard Gold On Exchange Plan",78.19%,0.790505779,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$900 ","$900 per person | $1800 per group",20.00%,,,,"$1,800 ","$1800 per person | $3600 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$900 ","$10 ","$2,330 ","$60 ","$120 ","$1,190 ","$0 ","$20 ",,,No,"Gold 900 Point","$900 ","$510 ","$240 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350033,"Gold 2000 Point",61589ID235,,IDN003,IDS001,IDF007,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350033-01,"Standard Gold On Exchange Plan",81.19%,0.779749197,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$4,000 ","$4000 per person | $8000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$120 ","$1,150 ","$0 ","$20 ",,,No,"Gold 2000 Point","$2,000 ","$480 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350038,"Bronze 6500 Point ",61589ID235,,IDN003,IDS001,IDF010,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350038-01,"Standard Bronze On Exchange Plan",64.14%,0.635186732,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,200 ","$9200 per person | $18400 per group",,,"$18,400 ","$18400 per person | $36800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",40.00%,,,,"$13,000 ","$13000 per person | $26000 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$10 ","$2,430 ","$60 ","$3,550 ","$670 ","$0 ","$20 ",,,No,"Bronze 6500 Point ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350039,"Bronze 6500 PQA Connect ",61589ID235,,IDN006,IDS001,IDF010,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350039-01,"Standard Bronze On Exchange Plan",64.14%,0.635186732,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,200 ","$9200 per person | $18400 per group",,,"$18,400 ","$18400 per person | $36800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",40.00%,,,,"$13,000 ","$13000 per person | $26000 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$10 ","$2,430 ","$60 ","$3,550 ","$670 ","$0 ","$20 ",,,No,"Bronze 6500 PQA Connect ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350040,"Bronze 6500 SAHA Connect ",61589ID235,,IDN009,IDS001,IDF010,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350040-01,"Standard Bronze On Exchange Plan",64.14%,0.635186732,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,200 ","$9200 per person | $18400 per group",,,"$18,400 ","$18400 per person | $36800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",40.00%,,,,"$13,000 ","$13000 per person | $26000 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$10 ","$2,430 ","$60 ","$3,550 ","$670 ","$0 ","$20 ",,,No,"Bronze 6500 SAHA Connect ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350041,"Bronze 6500 IDID ",61589ID235,,IDN008,IDS001,IDF010,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350041-01,"Standard Bronze On Exchange Plan",64.14%,0.635186732,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,200 ","$9200 per person | $18400 per group",,,"$18,400 ","$18400 per person | $36800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",40.00%,,,,"$13,000 ","$13000 per person | $26000 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$10 ","$2,430 ","$60 ","$3,550 ","$670 ","$0 ","$20 ",,,No,"Bronze 6500 IDID ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350045,"Silver 5500 Point",61589ID235,,IDN003,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350045-01,"Standard Silver On Exchange Plan",71.61%,0.708275895,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,550 ","$8550 per person | $17100 per group",,,"$17,100 ","$17100 per person | $34200 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",30.00%,,,,"$11,000 ","$11000 per person | $22000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,120 ","$60 ","$120 ","$1,230 ","$0 ","$20 ",,,No,"Silver 5500 Point","$2,450 ","$160 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350046,"Silver 5500 PQA Connect",61589ID235,,IDN006,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350046-01,"Standard Silver On Exchange Plan",71.61%,0.708275895,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,550 ","$8550 per person | $17100 per group",,,"$17,100 ","$17100 per person | $34200 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",30.00%,,,,"$11,000 ","$11000 per person | $22000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,120 ","$60 ","$120 ","$1,230 ","$0 ","$20 ",,,No,"Silver 5500 PQA Connect","$2,450 ","$160 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350047,"Silver 5500 SAHA Connect",61589ID235,,IDN009,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350047-01,"Standard Silver On Exchange Plan",71.61%,0.708275895,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,550 ","$8550 per person | $17100 per group",,,"$17,100 ","$17100 per person | $34200 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",30.00%,,,,"$11,000 ","$11000 per person | $22000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,120 ","$60 ","$120 ","$1,230 ","$0 ","$20 ",,,No,"Silver 5500 SAHA Connect","$2,450 ","$160 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350048,"Silver 5500 IDID",61589ID235,,IDN008,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350048-01,"Standard Silver On Exchange Plan",71.61%,0.708275895,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,550 ","$8550 per person | $17100 per group",,,"$17,100 ","$17100 per person | $34200 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",30.00%,,,,"$11,000 ","$11000 per person | $22000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,120 ","$60 ","$120 ","$1,230 ","$0 ","$20 ",,,No,"Silver 5500 IDID","$2,450 ","$160 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350064,"Silver 4500 IDID",61589ID235,,IDN008,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350064-01,"Standard Silver On Exchange Plan",71.55%,0.708806248,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,800 ","$8800 per person | $17600 per group",,,"$17,600 ","$17600 per person | $35200 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$10 ","$2,420 ","$60 ","$120 ","$1,310 ","$0 ","$20 ",,,No,"Silver 4500 IDID","$2,450 ","$190 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350079,"Gold 2000 IDID ",61589ID235,,IDN008,IDS001,IDF007,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350079-01,"Standard Gold On Exchange Plan",81.19%,0.779749197,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$4,000 ","$4000 per person | $8000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$120 ","$1,150 ","$0 ","$20 ",,,No,"Gold 2000 IDID ","$2,000 ","$480 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350087,"Gold 900 IDID",61589ID235,,IDN008,IDS001,IDF007,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350087-01,"Standard Gold On Exchange Plan",78.19%,0.790505779,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$900 ","$900 per person | $1800 per group",20.00%,,,,"$1,800 ","$1800 per person | $3600 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$900 ","$10 ","$2,330 ","$60 ","$120 ","$1,190 ","$0 ","$20 ",,,No,"Gold 900 IDID","$900 ","$510 ","$240 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350093,"Bronze HSA 7150 Point",61589ID235,,IDN003,IDS001,IDF011,Existing,POS,"Expanded Bronze",No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350093-01,"Standard Bronze On Exchange Plan",,0.64718734,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,150 ","$7150 per person | $14300 per group",,,"$14,300 ","$14300 per person | $28600 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,150 ","$7150 per person | $14300 per group",0.00%,,,,"$14,300 ","$14300 per person | $28600 per group","Not Applicable","per person not applicable | per group not applicable","$7,150 ","$0 ","$0 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",,,No,"Bronze HSA 7150 Point","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350094,"Bronze HSA 7150 PQA Connect",61589ID235,,IDN006,IDS001,IDF011,Existing,POS,"Expanded Bronze",No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350094-01,"Standard Bronze On Exchange Plan",,0.64718734,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,150 ","$7150 per person | $14300 per group",,,"$14,300 ","$14300 per person | $28600 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,150 ","$7150 per person | $14300 per group",0.00%,,,,"$14,300 ","$14300 per person | $28600 per group","Not Applicable","per person not applicable | per group not applicable","$7,150 ","$0 ","$0 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",,,No,"Bronze HSA 7150 PQA Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350095,"Bronze HSA 7150 SAHA Connect",61589ID235,,IDN009,IDS001,IDF011,Existing,POS,"Expanded Bronze",No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350095-01,"Standard Bronze On Exchange Plan",,0.64718734,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,150 ","$7150 per person | $14300 per group",,,"$14,300 ","$14300 per person | $28600 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,150 ","$7150 per person | $14300 per group",0.00%,,,,"$14,300 ","$14300 per person | $28600 per group","Not Applicable","per person not applicable | per group not applicable","$7,150 ","$0 ","$0 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",,,No,"Bronze HSA 7150 SAHA Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350096,"Bronze HSA 7150 IDID",61589ID235,,IDN008,IDS001,IDF011,Existing,POS,"Expanded Bronze",No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350096-01,"Standard Bronze On Exchange Plan",,0.64718734,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,150 ","$7150 per person | $14300 per group",,,"$14,300 ","$14300 per person | $28600 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,150 ","$7150 per person | $14300 per group",0.00%,,,,"$14,300 ","$14300 per person | $28600 per group","Not Applicable","per person not applicable | per group not applicable","$7,150 ","$0 ","$0 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",,,No,"Bronze HSA 7150 IDID","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350097,"Bronze 7500 Point",61589ID235,,IDN003,IDS001,IDF010,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350097-01,"Standard Bronze On Exchange Plan",63.33%,0.631059841,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,300 ","$9300 per person | $18600 per group",,,"$18,600 ","$18600 per person | $37200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$10 ","$1,790 ","$60 ","$3,550 ","$670 ","$0 ","$20 ",,,No,"Bronze 7500 Point","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350098,"Bronze 7500 PQA Connect",61589ID235,,IDN006,IDS001,IDF010,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350098-01,"Standard Bronze On Exchange Plan",63.33%,0.631059841,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,300 ","$9300 per person | $18600 per group",,,"$18,600 ","$18600 per person | $37200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$10 ","$1,790 ","$60 ","$3,550 ","$670 ","$0 ","$20 ",,,No,"Bronze 7500 PQA Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350099,"Bronze 7500 SAHA Connect",61589ID235,,IDN009,IDS001,IDF010,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350099-01,"Standard Bronze On Exchange Plan",63.33%,0.631059841,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,300 ","$9300 per person | $18600 per group",,,"$18,600 ","$18600 per person | $37200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$10 ","$1,790 ","$60 ","$3,550 ","$670 ","$0 ","$20 ",,,No,"Bronze 7500 SAHA Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350100,"Bronze 7500 IDID",61589ID235,,IDN008,IDS001,IDF010,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350100-01,"Standard Bronze On Exchange Plan",63.33%,0.631059841,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,300 ","$9300 per person | $18600 per group",,,"$18,600 ","$18600 per person | $37200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$10 ","$1,790 ","$60 ","$3,550 ","$670 ","$0 ","$20 ",,,No,"Bronze 7500 IDID","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350101,"Silver 6500 PQA Connect",61589ID235,,IDN006,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350101-01,"Standard Silver On Exchange Plan",71.71%,0.710402688,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,450 ","$7450 per person | $14900 per group",,,"$14,900 ","$14900 per person | $29800 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$6500 per person | $13000 per group",30.00%,,,,"$13,000 ","$13000 per person | $26000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$6,500 ","$10 ","$940 ","$60 ","$280 ","$950 ","$0 ","$20 ",,,No,"Silver 6500 PQA Connect","$2,450 ","$190 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350102,"Silver 6500 SAHA Connect",61589ID235,,IDN009,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350102-01,"Standard Silver On Exchange Plan",71.71%,0.710402688,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,450 ","$7450 per person | $14900 per group",,,"$14,900 ","$14900 per person | $29800 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$6500 per person | $13000 per group",30.00%,,,,"$13,000 ","$13000 per person | $26000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$6,500 ","$10 ","$940 ","$60 ","$280 ","$950 ","$0 ","$20 ",,,No,"Silver 6500 SAHA Connect","$2,450 ","$190 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350103,"Silver 6500 Point",61589ID235,,IDN003,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350103-01,"Standard Silver On Exchange Plan",71.71%,0.710402688,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,450 ","$7450 per person | $14900 per group",,,"$14,900 ","$14900 per person | $29800 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$6500 per person | $13000 per group",30.00%,,,,"$13,000 ","$13000 per person | $26000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$6,500 ","$10 ","$940 ","$60 ","$280 ","$950 ","$0 ","$20 ",,,No,"Silver 6500 Point","$2,450 ","$190 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350104,"Silver 6500 IDID",61589ID235,,IDN008,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350104-01,"Standard Silver On Exchange Plan",71.71%,0.710402688,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,450 ","$7450 per person | $14900 per group",,,"$14,900 ","$14900 per person | $29800 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$6500 per person | $13000 per group",30.00%,,,,"$13,000 ","$13000 per person | $26000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$6,500 ","$10 ","$940 ","$60 ","$280 ","$950 ","$0 ","$20 ",,,No,"Silver 6500 IDID","$2,450 ","$190 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350105,"Silver HSA 5300 Point",61589ID235,,IDN003,IDS001,IDF011,Existing,POS,Silver,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350105-01,"Standard Silver On Exchange Plan",,0.713281073,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,300 ","$5300 per person | $10600 per group",,,"$10,600 ","$10600 per person | $21200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,300 ","$5300 per person | $10600 per group",0.00%,,,,"$10,600 ","$10600 per person | $21200 per group","Not Applicable","per person not applicable | per group not applicable","$5,300 ","$0 ","$0 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",,,No,"Silver HSA 5300 Point","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350106,"Silver HSA 5300 PQA Connect",61589ID235,,IDN006,IDS001,IDF011,Existing,POS,Silver,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350106-01,"Standard Silver On Exchange Plan",,0.713281073,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,300 ","$5300 per person | $10600 per group",,,"$10,600 ","$10600 per person | $21200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,300 ","$5300 per person | $10600 per group",0.00%,,,,"$10,600 ","$10600 per person | $21200 per group","Not Applicable","per person not applicable | per group not applicable","$5,300 ","$0 ","$0 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",,,No,"Silver HSA 5300 PQA Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350107,"Silver HSA 5300 SAHA Connect",61589ID235,,IDN009,IDS001,IDF011,Existing,POS,Silver,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350107-01,"Standard Silver On Exchange Plan",,0.713281073,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,300 ","$5300 per person | $10600 per group",,,"$10,600 ","$10600 per person | $21200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,300 ","$5300 per person | $10600 per group",0.00%,,,,"$10,600 ","$10600 per person | $21200 per group","Not Applicable","per person not applicable | per group not applicable","$5,300 ","$0 ","$0 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",,,No,"Silver HSA 5300 SAHA Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350108,"Silver HSA 5300 IDID",61589ID235,,IDN008,IDS001,IDF011,Existing,POS,Silver,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350108-01,"Standard Silver On Exchange Plan",,0.713281073,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,300 ","$5300 per person | $10600 per group",,,"$10,600 ","$10600 per person | $21200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,300 ","$5300 per person | $10600 per group",0.00%,,,,"$10,600 ","$10600 per person | $21200 per group","Not Applicable","per person not applicable | per group not applicable","$5,300 ","$0 ","$0 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",,,No,"Silver HSA 5300 IDID","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350109,"Silver HSA 3200 Point",61589ID235,,IDN003,IDS001,IDF012,Existing,POS,Silver,Yes,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350109-01,"Standard Silver On Exchange Plan",71.43%,0.719605817,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,600 ","$6600 per person | $13200 per group",,,"$13,200 ","$13200 per person | $26400 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,200 ","$3200 per person | $6400 per group",30.00%,,,,"$6,400 ","$6400 per person | $12800 per group","Not Applicable","per person not applicable | per group not applicable","$3,200 ","$0 ","$2,810 ","$60 ","$3,200 ","$315 ","$340 ","$20 ",,,No,"Silver HSA 3200 Point","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350110,"Silver HSA 3200 PQA Connect",61589ID235,,IDN006,IDS001,IDF012,Existing,POS,Silver,Yes,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350110-01,"Standard Silver On Exchange Plan",71.43%,0.719605817,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,600 ","$6600 per person | $13200 per group",,,"$13,200 ","$13200 per person | $26400 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,200 ","$3200 per person | $6400 per group",30.00%,,,,"$6,400 ","$6400 per person | $12800 per group","Not Applicable","per person not applicable | per group not applicable","$3,200 ","$0 ","$2,810 ","$60 ","$3,200 ","$315 ","$340 ","$20 ",,,No,"Silver HSA 3200 PQA Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350111,"Silver HSA 3200 SAHA Connect",61589ID235,,IDN009,IDS001,IDF012,Existing,POS,Silver,Yes,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350111-01,"Standard Silver On Exchange Plan",71.43%,0.719605817,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,600 ","$6600 per person | $13200 per group",,,"$13,200 ","$13200 per person | $26400 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,200 ","$3200 per person | $6400 per group",30.00%,,,,"$6,400 ","$6400 per person | $12800 per group","Not Applicable","per person not applicable | per group not applicable","$3,200 ","$0 ","$2,810 ","$60 ","$3,200 ","$315 ","$340 ","$20 ",,,No,"Silver HSA 3200 SAHA Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350112,"Silver HSA 3200 IDID",61589ID235,,IDN008,IDS001,IDF012,Existing,POS,Silver,Yes,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350112-01,"Standard Silver On Exchange Plan",71.43%,0.719605817,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,600 ","$6600 per person | $13200 per group",,,"$13,200 ","$13200 per person | $26400 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,200 ","$3200 per person | $6400 per group",30.00%,,,,"$6,400 ","$6400 per person | $12800 per group","Not Applicable","per person not applicable | per group not applicable","$3,200 ","$0 ","$2,810 ","$60 ","$3,200 ","$315 ","$340 ","$20 ",,,No,"Silver HSA 3200 IDID","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350114,"Gold 900 MVN Connect",61589ID235,,IDN005,IDS001,IDF007,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350114-01,"Standard Gold On Exchange Plan",78.19%,0.790505779,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$900 ","$900 per person | $1800 per group",20.00%,,,,"$1,800 ","$1800 per person | $3600 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$900 ","$10 ","$2,330 ","$60 ","$120 ","$1,190 ","$0 ","$20 ",,,No,"Gold 900 MVN Connect","$900 ","$510 ","$240 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350116,"Gold 2000 MVN Connect",61589ID235,,IDN005,IDS001,IDF007,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350116-01,"Standard Gold On Exchange Plan",81.19%,0.779749197,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$4,000 ","$4000 per person | $8000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$120 ","$1,150 ","$0 ","$20 ",,,No,"Gold 2000 MVN Connect","$2,000 ","$480 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350119,"Silver 4500 MVN Connect",61589ID235,,IDN005,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350119-01,"Standard Silver On Exchange Plan",71.55%,0.708806248,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,800 ","$8800 per person | $17600 per group",,,"$17,600 ","$17600 per person | $35200 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$4,500 ","$10 ","$2,420 ","$60 ","$120 ","$1,310 ","$0 ","$20 ",,,No,"Silver 4500 MVN Connect","$2,450 ","$190 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350121,"Silver 5500 MVN Connect",61589ID235,,IDN005,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350121-01,"Standard Silver On Exchange Plan",71.61%,0.708275895,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,550 ","$8550 per person | $17100 per group",,,"$17,100 ","$17100 per person | $34200 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",30.00%,,,,"$11,000 ","$11000 per person | $22000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,120 ","$60 ","$120 ","$1,230 ","$0 ","$20 ",,,No,"Silver 5500 MVN Connect","$2,450 ","$160 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350122,"Silver 6500 MVN Connect",61589ID235,,IDN005,IDS001,IDF007,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350122-01,"Standard Silver On Exchange Plan",71.71%,0.710402688,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,450 ","$7450 per person | $14900 per group",,,"$14,900 ","$14900 per person | $29800 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$6500 per person | $13000 per group",30.00%,,,,"$13,000 ","$13000 per person | $26000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$6,500 ","$10 ","$940 ","$60 ","$280 ","$950 ","$0 ","$20 ",,,No,"Silver 6500 MVN Connect","$2,450 ","$190 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350123,"Bronze 9000 MVN Connect Deductible-First",61589ID235,,IDN005,IDS001,IDF009,Existing,POS,Bronze,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350123-01,"Standard Bronze On Exchange Plan",61.49%,0.610350587,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",0.00%,,,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable","$9,000 ","$0 ","$0 ","$60 ","$4,420 ","$370 ","$0 ","$20 ",,,No,"Bronze 9000 MVN Connect Deductible-First","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350124,"Bronze 7500 MVN Connect",61589ID235,,IDN005,IDS001,IDF010,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350124-01,"Standard Bronze On Exchange Plan",63.33%,0.631059841,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,300 ","$9300 per person | $18600 per group",,,"$18,600 ","$18600 per person | $37200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$10 ","$1,790 ","$60 ","$3,550 ","$670 ","$0 ","$20 ",,,No,"Bronze 7500 MVN Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350125,"Bronze HSA 7150 MVN Connect",61589ID235,,IDN005,IDS001,IDF011,Existing,POS,"Expanded Bronze",No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350125-01,"Standard Bronze On Exchange Plan",,0.64718734,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,150 ","$7150 per person | $14300 per group",,,"$14,300 ","$14300 per person | $28600 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,150 ","$7150 per person | $14300 per group",0.00%,,,,"$14,300 ","$14300 per person | $28600 per group","Not Applicable","per person not applicable | per group not applicable","$7,150 ","$0 ","$0 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",,,No,"Bronze HSA 7150 MVN Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350126,"Silver HSA 5300 MVN Connect",61589ID235,,IDN005,IDS001,IDF011,Existing,POS,Silver,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350126-01,"Standard Silver On Exchange Plan",,0.713281073,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,300 ","$5300 per person | $10600 per group",,,"$10,600 ","$10600 per person | $21200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,300 ","$5300 per person | $10600 per group",0.00%,,,,"$10,600 ","$10600 per person | $21200 per group","Not Applicable","per person not applicable | per group not applicable","$5,300 ","$0 ","$0 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",,,No,"Silver HSA 5300 MVN Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350127,"Silver HSA 3200 MVN Connect",61589ID235,,IDN005,IDS001,IDF012,Existing,POS,Silver,Yes,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350127-01,"Standard Silver On Exchange Plan",71.43%,0.719605817,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,600 ","$6600 per person | $13200 per group",,,"$13,200 ","$13200 per person | $26400 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,200 ","$3200 per person | $6400 per group",30.00%,,,,"$6,400 ","$6400 per person | $12800 per group","Not Applicable","per person not applicable | per group not applicable","$3,200 ","$0 ","$2,810 ","$60 ","$3,200 ","$315 ","$340 ","$20 ",,,No,"Silver HSA 3200 MVN Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350128,"Bronze 6500 MVN Connect ",61589ID235,,IDN005,IDS001,IDF010,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350128-01,"Standard Bronze On Exchange Plan",64.14%,0.635186732,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,200 ","$9200 per person | $18400 per group",,,"$18,400 ","$18400 per person | $36800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",40.00%,,,,"$13,000 ","$13000 per person | $26000 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$10 ","$2,430 ","$60 ","$3,550 ","$670 ","$0 ","$20 ",,,No,"Bronze 6500 MVN Connect ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350129,"Bronze 9000 Point Deductible-First",61589ID235,,IDN003,IDS001,IDF009,Existing,POS,Bronze,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350129-01,"Standard Bronze On Exchange Plan",61.49%,0.610350587,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",0.00%,,,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable","$9,000 ","$0 ","$0 ","$60 ","$4,420 ","$370 ","$0 ","$20 ",,,No,"Bronze 9000 Point Deductible-First","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350130,"Bronze 9000 PQA Connect Deductible-First",61589ID235,,IDN006,IDS001,IDF009,Existing,POS,Bronze,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350130-01,"Standard Bronze On Exchange Plan",61.49%,0.610350587,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",0.00%,,,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable","$9,000 ","$0 ","$0 ","$60 ","$4,420 ","$370 ","$0 ","$20 ",,,No,"Bronze 9000 PQA Connect Deductible-First","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350131,"Bronze 9000 SAHA Connect Deductible-First",61589ID235,,IDN009,IDS001,IDF009,Existing,POS,Bronze,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350131-01,"Standard Bronze On Exchange Plan",61.49%,0.610350587,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",0.00%,,,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable","$9,000 ","$0 ","$0 ","$60 ","$4,420 ","$370 ","$0 ","$20 ",,,No,"Bronze 9000 SAHA Connect Deductible-First","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350132,"Bronze 9000 IDID Deductible-First",61589ID235,,IDN008,IDS001,IDF009,Existing,POS,Bronze,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350132-01,"Standard Bronze On Exchange Plan",61.49%,0.610350587,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,000 ","$9000 per person | $18000 per group",0.00%,,,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable","$9,000 ","$0 ","$0 ","$60 ","$4,420 ","$370 ","$0 ","$20 ",,,No,"Bronze 9000 IDID Deductible-First","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350133,"Gold HSA 3700 PQA Connect",61589ID235,,IDN006,IDS001,IDF011,Existing,POS,Gold,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350133-01,"Standard Gold On Exchange Plan",,0.781982573,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,700 ","$3700 per person | $7400 per group",,,"$7,400 ","$7400 per person | $14800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,700 ","$3700 per person | $7400 per group",0.00%,,,,"$7,400 ","$7400 per person | $14800 per group","Not Applicable","per person not applicable | per group not applicable","$3,700 ","$0 ","$0 ","$60 ","$3,700 ","$0 ","$0 ","$20 ",,,No,"Gold HSA 3700 PQA Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350134,"Gold HSA 3700 SAHA Connect",61589ID235,,IDN009,IDS001,IDF011,Existing,POS,Gold,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350134-01,"Standard Gold On Exchange Plan",,0.781982573,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,700 ","$3700 per person | $7400 per group",,,"$7,400 ","$7400 per person | $14800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,700 ","$3700 per person | $7400 per group",0.00%,,,,"$7,400 ","$7400 per person | $14800 per group","Not Applicable","per person not applicable | per group not applicable","$3,700 ","$0 ","$0 ","$60 ","$3,700 ","$0 ","$0 ","$20 ",,,No,"Gold HSA 3700 SAHA Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350135,"Gold HSA 3700 IDID",61589ID235,,IDN008,IDS001,IDF011,Existing,POS,Gold,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350135-01,"Standard Gold On Exchange Plan",,0.781982573,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,700 ","$3700 per person | $7400 per group",,,"$7,400 ","$7400 per person | $14800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,700 ","$3700 per person | $7400 per group",0.00%,,,,"$7,400 ","$7400 per person | $14800 per group","Not Applicable","per person not applicable | per group not applicable","$3,700 ","$0 ","$0 ","$60 ","$3,700 ","$0 ","$0 ","$20 ",,,No,"Gold HSA 3700 IDID","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350136,"Gold HSA 3700 MVN Connect",61589ID235,,IDN005,IDS001,IDF011,Existing,POS,Gold,No,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350136-01,"Standard Gold On Exchange Plan",,0.781982573,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,700 ","$3700 per person | $7400 per group",,,"$7,400 ","$7400 per person | $14800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,700 ","$3700 per person | $7400 per group",0.00%,,,,"$7,400 ","$7400 per person | $14800 per group","Not Applicable","per person not applicable | per group not applicable","$3,700 ","$0 ","$0 ","$60 ","$3,700 ","$0 ","$0 ","$20 ",,,No,"Gold HSA 3700 MVN Connect","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350137,"Gold 3000 PQA Connect ",61589ID235,,IDN006,IDS001,IDF007,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350137-01,"Standard Gold On Exchange Plan",78.05%,0.774208788,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,200 ","$6200 per person | $12400 per group",,,"$12,400 ","$12400 per person | $24800 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",20.00%,,,,"$6,000 ","$6000 per person | $12000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$10 ","$1,910 ","$60 ","$120 ","$1,110 ","$0 ","$20 ",,,No,"Gold 3000 PQA Connect ","$2,450 ","$130 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350138,"Gold 3000 SAHA Connect",61589ID235,,IDN009,IDS001,IDF007,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350138-01,"Standard Gold On Exchange Plan",78.05%,0.774208788,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,200 ","$6200 per person | $12400 per group",,,"$12,400 ","$12400 per person | $24800 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",20.00%,,,,"$6,000 ","$6000 per person | $12000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$10 ","$1,910 ","$60 ","$120 ","$1,110 ","$0 ","$20 ",,,No,"Gold 3000 SAHA Connect","$2,450 ","$130 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350139,"Gold 3000 IDID",61589ID235,,IDN008,IDS001,IDF007,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350139-01,"Standard Gold On Exchange Plan",78.05%,0.774208788,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,200 ","$6200 per person | $12400 per group",,,"$12,400 ","$12400 per person | $24800 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",20.00%,,,,"$6,000 ","$6000 per person | $12000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$10 ","$1,910 ","$60 ","$120 ","$1,110 ","$0 ","$20 ",,,No,"Gold 3000 IDID","$2,450 ","$130 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350140,"Gold 3000 MVN Connect",61589ID235,,IDN005,IDS001,IDF007,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350140-01,"Standard Gold On Exchange Plan",78.05%,0.774208788,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,200 ","$6200 per person | $12400 per group",,,"$12,400 ","$12400 per person | $24800 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",20.00%,,,,"$6,000 ","$6000 per person | $12000 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$10 ","$1,910 ","$60 ","$120 ","$1,110 ","$0 ","$20 ",,,No,"Gold 3000 MVN Connect","$2,450 ","$130 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350141,"Silver Copay 2000 PQA Connect",61589ID235,,IDN006,IDS001,IDF008,New,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350141-01,"Standard Silver On Exchange Plan",69.70%,0.719717147,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$2,000 ","$2000 per person | $4000 per group",50.00%,,,,"$4,000 ","$4000 per person | $8000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$1,360 ","$4,540 ","$60 ","$2,000 ","$1,010 ","$340 ","$20 ",,,No,"Silver Copay 2000 PQA Connect","$1,235 ","$1,200 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350142,"Silver Copay 2000 SAHA Connect",61589ID235,,IDN009,IDS001,IDF008,New,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350142-01,"Standard Silver On Exchange Plan",69.70%,0.719717147,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$2,000 ","$2000 per person | $4000 per group",50.00%,,,,"$4,000 ","$4000 per person | $8000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$1,360 ","$4,540 ","$60 ","$2,000 ","$1,010 ","$340 ","$20 ",,,No,"Silver Copay 2000 SAHA Connect","$1,235 ","$1,200 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350143,"Silver Copay 2000 IDID",61589ID235,,IDN008,IDS001,IDF008,New,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350143-01,"Standard Silver On Exchange Plan",69.70%,0.719717147,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$2,000 ","$2000 per person | $4000 per group",50.00%,,,,"$4,000 ","$4000 per person | $8000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$1,360 ","$4,540 ","$60 ","$2,000 ","$1,010 ","$340 ","$20 ",,,No,"Silver Copay 2000 IDID","$1,235 ","$1,200 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,61589ID2350144,"Silver Copay 2000 MVN Connect",61589ID235,,IDN005,IDS001,IDF008,New,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act. ",Yes,,,,,61589ID2350144-01,"Standard Silver On Exchange Plan",69.70%,0.719717147,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$2,000 ","$2000 per person | $4000 per group",50.00%,,,,"$4,000 ","$4000 per person | $8000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$1,360 ","$4,540 ","$60 ","$2,000 ","$1,010 ","$340 ","$20 ",,,No,"Silver Copay 2000 MVN Connect","$1,235 ","$1,200 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360001,"PQA Southeast Catastrophic Connect 9450",61589ID236,,IDN006,IDS007,IDF003,Existing,POS,Catastrophic,No,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,3,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360001-01,"Standard Catastrophic On Exchange Plan",,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",0.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$9,450 ","$0 ","$0 ","$60 ","$4,700 ","$90 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Catastrophic Connect 9450","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360003,"PQA Southeast Bronze HSA Connect 6250",61589ID236,,IDN006,IDS007,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,Yes,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360003-01,"Standard Bronze On Exchange Plan",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Bronze HSA Connect 6250","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360003,"PQA Southeast Bronze HSA Connect 6250",61589ID236,,IDN006,IDS007,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360003-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"PQA Southeast Bronze Connect 6250 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360003,"PQA Southeast Bronze HSA Connect 6250",61589ID236,,IDN006,IDS007,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360003-03,"Limited Cost Sharing Plan Variation",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Bronze Connect 6250 Tribal ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360006,"PQA Southeast Silver Connect 5500",61589ID236,,IDN006,IDS007,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360006-01,"Standard Silver On Exchange Plan",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Connect 5500","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360006,"PQA Southeast Silver Connect 5500",61589ID236,,IDN006,IDS007,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360006-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"PQA Southeast Silver Connect 5500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360006,"PQA Southeast Silver Connect 5500",61589ID236,,IDN006,IDS007,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360006-03,"Limited Cost Sharing Plan Variation",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Connect 5500 Tribal ","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360006,"PQA Southeast Silver Connect 5500",61589ID236,,IDN006,IDS007,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360006-04,"73% AV Level Silver Plan",73.85%,0.733866356,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$4,750 ","$4750 per person | $9500 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$4,750 ","$10 ","$2,340 ","$60 ","$1,120 ","$870 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Connect 5500 CSR 73","$2,450 ","$170 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360006,"PQA Southeast Silver Connect 5500",61589ID236,,IDN006,IDS007,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360006-05,"87% AV Level Silver Plan",87.20%,0.867604964,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,700 ","$2700 per person | $5400 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$650 ","$650 per person | $1300 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$650 ","$10 ","$2,040 ","$60 ","$370 ","$950 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Connect 5500 CSR 87","$650 ","$510 ","$290 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360006,"PQA Southeast Silver Connect 5500",61589ID236,,IDN006,IDS007,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360006-06,"94% AV Level Silver Plan",94.09%,0.936850326,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,300 ","$1300 per person | $2600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | per group not applicable",,,,,,,,,,,"$0 ","$10 ","$1,290 ","$60 ","$100 ","$810 ","$20 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Connect 5500 CSR 94","$0 ","$270 ","$440 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360008,"PQA Southeast Gold Connect 2000",61589ID236,,IDN006,IDS008,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360008-01,"Standard Gold On Exchange Plan",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Gold Connect 2000","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360008,"PQA Southeast Gold Connect 2000",61589ID236,,IDN006,IDS008,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360008-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"PQA Southeast Gold Connect 2000 Tribal 0 ","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360008,"PQA Southeast Gold Connect 2000",61589ID236,,IDN006,IDS008,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360008-03,"Limited Cost Sharing Plan Variation",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Gold Connect 2000 Tribal ","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360025,"Hometown East Catastrophic 9450",61589ID236,,IDN004,IDS003,IDF003,Existing,POS,Catastrophic,No,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,3,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360025-01,"Standard Catastrophic On Exchange Plan",,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",0.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$9,450 ","$0 ","$0 ","$60 ","$4,700 ","$90 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Catastrophic 9450","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360027,"Hometown East Bronze HSA 6250",61589ID236,,IDN004,IDS003,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,Yes,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360027-01,"Standard Bronze On Exchange Plan",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Bronze HSA 6250","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360027,"Hometown East Bronze HSA 6250",61589ID236,,IDN004,IDS003,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360027-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown East Bronze 6250 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360027,"Hometown East Bronze HSA 6250",61589ID236,,IDN004,IDS003,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360027-03,"Limited Cost Sharing Plan Variation",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Bronze 6250 Tribal ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360030,"Hometown East Silver 5500",61589ID236,,IDN004,IDS003,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360030-01,"Standard Silver On Exchange Plan",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver 5500","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360030,"Hometown East Silver 5500",61589ID236,,IDN004,IDS003,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360030-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown East Silver 5500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360030,"Hometown East Silver 5500",61589ID236,,IDN004,IDS003,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360030-03,"Limited Cost Sharing Plan Variation",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver 5500 Tribal","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360030,"Hometown East Silver 5500",61589ID236,,IDN004,IDS003,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360030-04,"73% AV Level Silver Plan",73.85%,0.733866356,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$4,750 ","$4750 per person | $9500 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$4,750 ","$10 ","$2,340 ","$60 ","$1,120 ","$870 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver 5500 CSR 73","$2,450 ","$170 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360030,"Hometown East Silver 5500",61589ID236,,IDN004,IDS003,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360030-05,"87% AV Level Silver Plan",87.20%,0.867604964,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,700 ","$2700 per person | $5400 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$650 ","$650 per person | $1300 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$650 ","$10 ","$2,040 ","$60 ","$370 ","$950 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver 5500 CSR 87","$650 ","$510 ","$290 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360030,"Hometown East Silver 5500",61589ID236,,IDN004,IDS003,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360030-06,"94% AV Level Silver Plan",94.09%,0.936850326,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,300 ","$1300 per person | $2600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | per group not applicable",,,,,,,,,,,"$0 ","$10 ","$1,290 ","$60 ","$100 ","$810 ","$20 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver 5500 CSR 94","$0 ","$270 ","$440 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360032,"Hometown East Gold 2000",61589ID236,,IDN004,IDS004,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360032-01,"Standard Gold On Exchange Plan",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Gold 2000","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360032,"Hometown East Gold 2000",61589ID236,,IDN004,IDS004,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360032-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown East Gold 2000 Tribal 0 ","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360032,"Hometown East Gold 2000",61589ID236,,IDN004,IDS004,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360032-03,"Limited Cost Sharing Plan Variation",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Gold 2000 Tribal ","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360033,"CPN North Central Catastrophic 9450",61589ID236,,IDN011,IDS015,IDF003,Existing,POS,Catastrophic,No,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,3,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360033-01,"Standard Catastrophic On Exchange Plan",,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",0.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$9,450 ","$0 ","$0 ","$60 ","$4,700 ","$90 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Catastrophic 9450","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360035,"CPN North Central Bronze HSA 6250",61589ID236,,IDN011,IDS015,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,Yes,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360035-01,"Standard Bronze On Exchange Plan",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Bronze HSA 6250","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360035,"CPN North Central Bronze HSA 6250",61589ID236,,IDN011,IDS015,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360035-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"CPN North Central Bronze 6250 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360035,"CPN North Central Bronze HSA 6250",61589ID236,,IDN011,IDS015,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360035-03,"Limited Cost Sharing Plan Variation",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Bronze 6250 Tribal ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360038,"CPN North Central Silver 5500",61589ID236,,IDN011,IDS015,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360038-01,"Standard Silver On Exchange Plan",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver 5500","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360038,"CPN North Central Silver 5500",61589ID236,,IDN011,IDS015,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360038-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"CPN North Central Silver 5500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360038,"CPN North Central Silver 5500",61589ID236,,IDN011,IDS015,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360038-03,"Limited Cost Sharing Plan Variation",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver 5500 Tribal","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360038,"CPN North Central Silver 5500",61589ID236,,IDN011,IDS015,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360038-04,"73% AV Level Silver Plan",73.85%,0.733866356,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$4,750 ","$4750 per person | $9500 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$4,750 ","$10 ","$2,340 ","$60 ","$1,120 ","$870 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver 5500 CSR 73","$2,450 ","$170 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360038,"CPN North Central Silver 5500",61589ID236,,IDN011,IDS015,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360038-05,"87% AV Level Silver Plan",87.20%,0.867604964,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,700 ","$2700 per person | $5400 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$650 ","$650 per person | $1300 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$650 ","$10 ","$2,040 ","$60 ","$370 ","$950 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver 5500 CSR 87","$650 ","$510 ","$290 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360038,"CPN North Central Silver 5500",61589ID236,,IDN011,IDS015,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360038-06,"94% AV Level Silver Plan",94.09%,0.936850326,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,300 ","$1300 per person | $2600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | per group not applicable",,,,,,,,,,,"$0 ","$10 ","$1,290 ","$60 ","$100 ","$810 ","$20 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver 5500 CSR 94","$0 ","$270 ","$440 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360040,"CPN North Central Gold 2000",61589ID236,,IDN011,IDS016,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360040-01,"Standard Gold On Exchange Plan",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Gold 2000","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360040,"CPN North Central Gold 2000",61589ID236,,IDN011,IDS016,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360040-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"CPN North Central Gold 2000 Tribal 0 ","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360040,"CPN North Central Gold 2000",61589ID236,,IDN011,IDS016,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360040-03,"Limited Cost Sharing Plan Variation",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Gold 2000 Tribal  ","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360049,"KCN North Catastrophic 9450",61589ID236,,IDN010,IDS013,IDF003,Existing,POS,Catastrophic,No,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,3,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360049-01,"Standard Catastrophic On Exchange Plan",,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",0.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$9,450 ","$0 ","$0 ","$60 ","$4,700 ","$90 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Catastrophic 9450","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360051,"KCN North Bronze HSA 6250",61589ID236,,IDN010,IDS013,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,Yes,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360051-01,"Standard Bronze On Exchange Plan",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Bronze HSA 6250","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360051,"KCN North Bronze HSA 6250",61589ID236,,IDN010,IDS013,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360051-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"KCN North Bronze 6250 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360051,"KCN North Bronze HSA 6250",61589ID236,,IDN010,IDS013,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360051-03,"Limited Cost Sharing Plan Variation",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Bronze 6250 Tribal ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360054,"KCN North Silver 5500",61589ID236,,IDN010,IDS013,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360054-01,"Standard Silver On Exchange Plan",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Silver 5500","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360054,"KCN North Silver 5500",61589ID236,,IDN010,IDS013,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360054-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"KCN North Silver 5500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360054,"KCN North Silver 5500",61589ID236,,IDN010,IDS013,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360054-03,"Limited Cost Sharing Plan Variation",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Silver 5500 Tribal","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360054,"KCN North Silver 5500",61589ID236,,IDN010,IDS013,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360054-04,"73% AV Level Silver Plan",73.85%,0.733866356,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$4,750 ","$4750 per person | $9500 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$4,750 ","$10 ","$2,340 ","$60 ","$1,120 ","$870 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Silver 5500 CSR 73","$2,450 ","$170 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360054,"KCN North Silver 5500",61589ID236,,IDN010,IDS013,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360054-05,"87% AV Level Silver Plan",87.20%,0.867604964,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,700 ","$2700 per person | $5400 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$650 ","$650 per person | $1300 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$650 ","$10 ","$2,040 ","$60 ","$370 ","$950 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Silver 5500 CSR 87","$650 ","$510 ","$290 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360054,"KCN North Silver 5500",61589ID236,,IDN010,IDS013,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360054-06,"94% AV Level Silver Plan",94.09%,0.936850326,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,300 ","$1300 per person | $2600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | per group not applicable",,,,,,,,,,,"$0 ","$10 ","$1,290 ","$60 ","$100 ","$810 ","$20 ","$20 ",100%,"Not Applicable",No,"KCN North Silver 5500 CSR 94","$0 ","$270 ","$440 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360056,"KCN North Gold 2000",61589ID236,,IDN010,IDS014,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360056-01,"Standard Gold On Exchange Plan",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Gold 2000","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360056,"KCN North Gold 2000",61589ID236,,IDN010,IDS014,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360056-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"KCN North Gold 2000 Tribal 0 ","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360056,"KCN North Gold 2000",61589ID236,,IDN010,IDS014,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360056-03,"Limited Cost Sharing Plan Variation",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Gold 2000 Tribal ","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360057,"Hometown North Catastrophic 9450",61589ID236,,IDN012,IDS017,IDF003,Existing,POS,Catastrophic,No,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,3,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360057-01,"Standard Catastrophic On Exchange Plan",,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",0.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$9,450 ","$0 ","$0 ","$60 ","$4,700 ","$90 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Catastrophic 9450","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360059,"Hometown North Bronze HSA 6250",61589ID236,,IDN012,IDS017,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,Yes,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360059-01,"Standard Bronze On Exchange Plan",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Bronze HSA 6250","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360059,"Hometown North Bronze HSA 6250",61589ID236,,IDN012,IDS017,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360059-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown North Bronze 6250 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360059,"Hometown North Bronze HSA 6250",61589ID236,,IDN012,IDS017,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360059-03,"Limited Cost Sharing Plan Variation",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Bronze 6250 Tribal ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360062,"Hometown North Silver 5500",61589ID236,,IDN012,IDS017,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360062-01,"Standard Silver On Exchange Plan",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver 5500","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360062,"Hometown North Silver 5500",61589ID236,,IDN012,IDS017,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360062-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown North Silver 5500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360062,"Hometown North Silver 5500",61589ID236,,IDN012,IDS017,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360062-03,"Limited Cost Sharing Plan Variation",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver 5500 Tribal","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360062,"Hometown North Silver 5500",61589ID236,,IDN012,IDS017,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360062-04,"73% AV Level Silver Plan",73.85%,0.733866356,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$4,750 ","$4750 per person | $9500 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$4,750 ","$10 ","$2,340 ","$60 ","$1,120 ","$870 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver 5500 CSR 73","$2,450 ","$170 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360062,"Hometown North Silver 5500",61589ID236,,IDN012,IDS017,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360062-05,"87% AV Level Silver Plan",87.20%,0.867604964,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,700 ","$2700 per person | $5400 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$650 ","$650 per person | $1300 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$650 ","$10 ","$2,040 ","$60 ","$370 ","$950 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver 5500 CSR 87","$650 ","$510 ","$290 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360062,"Hometown North Silver 5500",61589ID236,,IDN012,IDS017,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360062-06,"94% AV Level Silver Plan",94.09%,0.936850326,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,300 ","$1300 per person | $2600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | per group not applicable",,,,,,,,,,,"$0 ","$10 ","$1,290 ","$60 ","$100 ","$810 ","$20 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver 5500 CSR 94","$0 ","$270 ","$440 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360064,"Hometown North Gold 2000",61589ID236,,IDN012,IDS018,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360064-01,"Standard Gold On Exchange Plan",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Gold 2000","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360064,"Hometown North Gold 2000",61589ID236,,IDN012,IDS018,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360064-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown North Gold 2000 Tribal 0 ","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360064,"Hometown North Gold 2000",61589ID236,,IDN012,IDS018,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360064-03,"Limited Cost Sharing Plan Variation",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Gold 2000 Tribal ","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360073,"IDID Southwest Catastrophic 9450",61589ID236,,IDN008,IDS011,IDF003,Existing,POS,Catastrophic,No,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,3,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360073-01,"Standard Catastrophic On Exchange Plan",,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",0.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$9,450 ","$0 ","$0 ","$60 ","$4,700 ","$90 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Catastrophic 9450","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360075,"IDID Southwest Bronze HSA 6250",61589ID236,,IDN008,IDS011,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,Yes,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360075-01,"Standard Bronze On Exchange Plan",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Bronze HSA 6250","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360075,"IDID Southwest Bronze HSA 6250",61589ID236,,IDN008,IDS011,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360075-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"IDID Southwest Bronze 6250 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360075,"IDID Southwest Bronze HSA 6250",61589ID236,,IDN008,IDS011,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360075-03,"Limited Cost Sharing Plan Variation",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Bronze 6250 Tribal ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360078,"IDID Southwest Silver 5500",61589ID236,,IDN008,IDS011,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360078-01,"Standard Silver On Exchange Plan",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver 5500","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360078,"IDID Southwest Silver 5500",61589ID236,,IDN008,IDS011,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360078-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"IDID Southwest Silver 5500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360078,"IDID Southwest Silver 5500",61589ID236,,IDN008,IDS011,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360078-03,"Limited Cost Sharing Plan Variation",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver 5500 Tribal","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360078,"IDID Southwest Silver 5500",61589ID236,,IDN008,IDS011,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360078-04,"73% AV Level Silver Plan",73.85%,0.733866356,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$4,750 ","$4750 per person | $9500 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$4,750 ","$10 ","$2,340 ","$60 ","$1,120 ","$870 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver 5500 CSR 73","$2,450 ","$170 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360078,"IDID Southwest Silver 5500",61589ID236,,IDN008,IDS011,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360078-05,"87% AV Level Silver Plan",87.20%,0.867604964,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,700 ","$2700 per person | $5400 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$650 ","$650 per person | $1300 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$650 ","$10 ","$2,040 ","$60 ","$370 ","$950 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver 5500 CSR 87","$650 ","$510 ","$290 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360078,"IDID Southwest Silver 5500",61589ID236,,IDN008,IDS011,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360078-06,"94% AV Level Silver Plan",94.09%,0.936850326,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,300 ","$1300 per person | $2600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | per group not applicable",,,,,,,,,,,"$0 ","$10 ","$1,290 ","$60 ","$100 ","$810 ","$20 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver 5500 CSR 94","$0 ","$270 ","$440 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360080,"IDID Southwest Gold 2000",61589ID236,,IDN008,IDS012,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360080-01,"Standard Gold On Exchange Plan",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Gold 2000","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360080,"IDID Southwest Gold 2000",61589ID236,,IDN008,IDS012,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360080-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"IDID Southwest Gold 2000 Tribal 0 ","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360080,"IDID Southwest Gold 2000",61589ID236,,IDN008,IDS012,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360080-03,"Limited Cost Sharing Plan Variation",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Gold 2000 Tribal ","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360081,"SLHP Silver CarePoint 5500",61589ID236,,IDN007,IDS009,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360081-01,"Standard Silver On Exchange Plan",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Silver CarePoint 5500","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360081,"SLHP Silver CarePoint 5500",61589ID236,,IDN007,IDS009,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360081-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"SLHP Silver CarePoint 5500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360081,"SLHP Silver CarePoint 5500",61589ID236,,IDN007,IDS009,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360081-03,"Limited Cost Sharing Plan Variation",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Silver CarePoint 5500 Tribal  ","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360081,"SLHP Silver CarePoint 5500",61589ID236,,IDN007,IDS009,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360081-04,"73% AV Level Silver Plan",73.85%,0.733866356,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$4,750 ","$4750 per person | $9500 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$4,750 ","$10 ","$2,340 ","$60 ","$1,120 ","$870 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Silver CarePoint 5500 CSR 73","$2,450 ","$170 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360081,"SLHP Silver CarePoint 5500",61589ID236,,IDN007,IDS009,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360081-05,"87% AV Level Silver Plan",87.20%,0.867604964,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,700 ","$2700 per person | $5400 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$650 ","$650 per person | $1300 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$650 ","$10 ","$2,040 ","$60 ","$370 ","$950 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Silver CarePoint 5500 CSR 87","$650 ","$510 ","$290 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360081,"SLHP Silver CarePoint 5500",61589ID236,,IDN007,IDS009,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360081-06,"94% AV Level Silver Plan",94.09%,0.936850326,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,300 ","$1300 per person | $2600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | per group not applicable",,,,,,,,,,,"$0 ","$10 ","$1,290 ","$60 ","$100 ","$810 ","$20 ","$20 ",100%,"Not Applicable",No,"SLHP Silver CarePoint 5500 CSR 94","$0 ","$270 ","$440 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360090,"SLHP Gold CarePoint 2000",61589ID236,,IDN007,IDS010,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360090-01,"Standard Gold On Exchange Plan",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Gold CarePoint 2000","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360090,"SLHP Gold CarePoint 2000",61589ID236,,IDN007,IDS010,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360090-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"SLHP Gold CarePoint 2000 Tribal 0 ","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360090,"SLHP Gold CarePoint 2000",61589ID236,,IDN007,IDS010,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360090-03,"Limited Cost Sharing Plan Variation",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Gold CarePoint 2000 Tribal","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360091,"SLHP Catastrophic CarePoint 9450",61589ID236,,IDN007,IDS009,IDF003,Existing,POS,Catastrophic,No,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,3,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360091-01,"Standard Catastrophic On Exchange Plan",,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",0.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$9,450 ","$0 ","$0 ","$60 ","$4,700 ","$90 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Catastrophic CarePoint 9450","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360092,"SLHP Bronze HSA CarePoint 6250",61589ID236,,IDN007,IDS009,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,Yes,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360092-01,"Standard Bronze On Exchange Plan",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Bronze HSA CarePoint 6250","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360092,"SLHP Bronze HSA CarePoint 6250",61589ID236,,IDN007,IDS009,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360092-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"SLHP Bronze CarePoint 6250 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360092,"SLHP Bronze HSA CarePoint 6250",61589ID236,,IDN007,IDS009,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360092-03,"Limited Cost Sharing Plan Variation",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Bronze CarePoint 6250 Tribal  ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360113,"PQA Southeast Bronze Connect 7500",61589ID236,,IDN006,IDS007,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360113-01,"Standard Bronze On Exchange Plan",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Bronze Connect 7500","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360113,"PQA Southeast Bronze Connect 7500",61589ID236,,IDN006,IDS007,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360113-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"PQA Southeast Bronze Connect 7500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360113,"PQA Southeast Bronze Connect 7500",61589ID236,,IDN006,IDS007,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360113-03,"Limited Cost Sharing Plan Variation",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Bronze Connect 7500 Tribal ","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360115,"Hometown East Bronze 7500",61589ID236,,IDN004,IDS003,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360115-01,"Standard Bronze On Exchange Plan",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Bronze 7500","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360115,"Hometown East Bronze 7500",61589ID236,,IDN004,IDS003,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360115-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown East Bronze 7500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360115,"Hometown East Bronze 7500",61589ID236,,IDN004,IDS003,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360115-03,"Limited Cost Sharing Plan Variation",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Bronze 7500 Tribal ","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360116,"CPN North Central Bronze 7500",61589ID236,,IDN011,IDS015,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360116-01,"Standard Bronze On Exchange Plan",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Bronze 7500","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360116,"CPN North Central Bronze 7500",61589ID236,,IDN011,IDS015,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360116-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"CPN North Central Bronze 7500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360116,"CPN North Central Bronze 7500",61589ID236,,IDN011,IDS015,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360116-03,"Limited Cost Sharing Plan Variation",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Bronze 7500 Tribal ","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360117,"KCN North Bronze 7500",61589ID236,,IDN010,IDS013,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360117-01,"Standard Bronze On Exchange Plan",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Bronze 7500","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360117,"KCN North Bronze 7500",61589ID236,,IDN010,IDS013,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360117-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"KCN North Bronze 7500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360117,"KCN North Bronze 7500",61589ID236,,IDN010,IDS013,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360117-03,"Limited Cost Sharing Plan Variation",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Bronze 7500 Tribal ","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360118,"Hometown North Bronze 7500",61589ID236,,IDN012,IDS017,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360118-01,"Standard Bronze On Exchange Plan",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Bronze 7500","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360118,"Hometown North Bronze 7500",61589ID236,,IDN012,IDS017,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360118-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown North Bronze 7500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360118,"Hometown North Bronze 7500",61589ID236,,IDN012,IDS017,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360118-03,"Limited Cost Sharing Plan Variation",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Bronze 7500 Tribal ","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360120,"IDID Southwest Bronze 7500",61589ID236,,IDN008,IDS011,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360120-01,"Standard Bronze On Exchange Plan",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Bronze 7500","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360120,"IDID Southwest Bronze 7500",61589ID236,,IDN008,IDS011,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360120-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"IDID Southwest Bronze 7500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360120,"IDID Southwest Bronze 7500",61589ID236,,IDN008,IDS011,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360120-03,"Limited Cost Sharing Plan Variation",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Bronze 7500 Tribal ","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360121,"SLHP Bronze CarePoint 7500",61589ID236,,IDN007,IDS009,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360121-01,"Standard Bronze On Exchange Plan",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Bronze CarePoint 7500","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360121,"SLHP Bronze CarePoint 7500",61589ID236,,IDN007,IDS009,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360121-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"SLHP Bronze CarePoint 7500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360121,"SLHP Bronze CarePoint 7500",61589ID236,,IDN007,IDS009,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360121-03,"Limited Cost Sharing Plan Variation",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Bronze CarePoint 7500 Tribal ","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360122,"MVN East Catastrophic Connect 9450",61589ID236,,IDN005,IDS005,IDF003,Existing,POS,Catastrophic,No,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,3,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360122-01,"Standard Catastrophic On Exchange Plan",,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",0.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$9,450 ","$0 ","$0 ","$60 ","$4,700 ","$90 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Catastrophic Connect 9450","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360123,"MVN East Bronze Connect HSA 6250",61589ID236,,IDN005,IDS005,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,Yes,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360123-01,"Standard Bronze On Exchange Plan",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Bronze Connect HSA 6250","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360123,"MVN East Bronze Connect HSA 6250",61589ID236,,IDN005,IDS005,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360123-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"MVN East Bronze Connect 6250 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360123,"MVN East Bronze Connect HSA 6250",61589ID236,,IDN005,IDS005,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360123-03,"Limited Cost Sharing Plan Variation",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Bronze Connect 6250 Tribal ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360125,"MVN East Bronze Connect 7500",61589ID236,,IDN005,IDS005,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360125-01,"Standard Bronze On Exchange Plan",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Bronze Connect 7500","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360125,"MVN East Bronze Connect 7500",61589ID236,,IDN005,IDS005,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360125-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"MVN East Bronze Connect 7500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360125,"MVN East Bronze Connect 7500",61589ID236,,IDN005,IDS005,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360125-03,"Limited Cost Sharing Plan Variation",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Bronze Connect 7500 Tribal ","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360127,"MVN East Silver Connect 5500",61589ID236,,IDN005,IDS005,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360127-01,"Standard Silver On Exchange Plan",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Connect 5500","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360127,"MVN East Silver Connect 5500",61589ID236,,IDN005,IDS005,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360127-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"MVN East Silver Connect 5500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360127,"MVN East Silver Connect 5500",61589ID236,,IDN005,IDS005,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360127-03,"Limited Cost Sharing Plan Variation",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Connect 5500 Tribal","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360127,"MVN East Silver Connect 5500",61589ID236,,IDN005,IDS005,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360127-04,"73% AV Level Silver Plan",73.85%,0.733866356,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$4,750 ","$4750 per person | $9500 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$4,750 ","$10 ","$2,340 ","$60 ","$1,120 ","$870 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Connect 5500 CSR 73","$2,450 ","$170 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360127,"MVN East Silver Connect 5500",61589ID236,,IDN005,IDS005,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360127-05,"87% AV Level Silver Plan",87.20%,0.867604964,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,700 ","$2700 per person | $5400 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$650 ","$650 per person | $1300 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$650 ","$10 ","$2,040 ","$60 ","$370 ","$950 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Connect 5500 CSR 87","$650 ","$510 ","$290 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360127,"MVN East Silver Connect 5500",61589ID236,,IDN005,IDS005,IDF001,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360127-06,"94% AV Level Silver Plan",94.09%,0.936850326,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,300 ","$1300 per person | $2600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | per group not applicable",,,,,,,,,,,"$0 ","$10 ","$1,290 ","$60 ","$100 ","$810 ","$20 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Connect 5500 CSR 94","$0 ","$270 ","$440 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360129,"MVN East Gold Connect 2000",61589ID236,,IDN005,IDS006,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360129-01,"Standard Gold On Exchange Plan",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Gold Connect 2000","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360129,"MVN East Gold Connect 2000",61589ID236,,IDN005,IDS006,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360129-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"MVN East Gold Connect 2000 Tribal 0 ","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360129,"MVN East Gold Connect 2000",61589ID236,,IDN005,IDS006,IDF005,Existing,POS,Gold,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360129-03,"Limited Cost Sharing Plan Variation",79.37%,0.783231375,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,000 ","$10 ","$2,110 ","$60 ","$1,120 ","$800 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Gold Connect 2000 Tribal ","$2,000 ","$510 ","$20 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360139,"PQA Southeast Silver Copay Connect 3500",61589ID236,,IDN006,IDS007,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360139-01,"Standard Silver On Exchange Plan",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Copay Connect 3500","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360139,"PQA Southeast Silver Copay Connect 3500",61589ID236,,IDN006,IDS007,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360139-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"PQA Southeast Silver Copay Connect 3500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360139,"PQA Southeast Silver Copay Connect 3500",61589ID236,,IDN006,IDS007,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360139-03,"Limited Cost Sharing Plan Variation",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Copay Connect 3500 Tribal ","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360139,"PQA Southeast Silver Copay Connect 3500",61589ID236,,IDN006,IDS007,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360139-04,"73% AV Level Silver Plan",73.12%,0.71726152,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$1,360 ","$2,890 ","$60 ","$1,000 ","$1,100 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Copay Connect 3500 CSR 73","$1,980 ","$650 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360139,"PQA Southeast Silver Copay Connect 3500",61589ID236,,IDN006,IDS007,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360139-05,"87% AV Level Silver Plan",87.06%,0.865447614,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$200 ","$200 per person | $400 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$200 ","$1,160 ","$1,590 ","$60 ","$300 ","$980 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Copay Connect 3500 CSR 87","$200 ","$790 ","$570 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360139,"PQA Southeast Silver Copay Connect 3500",61589ID236,,IDN006,IDS007,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360139-06,"94% AV Level Silver Plan",94.46%,0.938607289,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,400 ","$1400 per person | $2800 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$240 ","$1,160 ","$60 ","$0 ","$680 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Copay Connect 3500 CSR 94","$0 ","$380 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360140,"Hometown East Silver Copay 3500",61589ID236,,IDN004,IDS003,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360140-01,"Standard Silver On Exchange Plan",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver Copay 3500","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360140,"Hometown East Silver Copay 3500",61589ID236,,IDN004,IDS003,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360140-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown East Silver Copay 3500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360140,"Hometown East Silver Copay 3500",61589ID236,,IDN004,IDS003,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360140-03,"Limited Cost Sharing Plan Variation",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver Copay 3500 Tribal","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360140,"Hometown East Silver Copay 3500",61589ID236,,IDN004,IDS003,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360140-04,"73% AV Level Silver Plan",73.12%,0.71726152,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$1,360 ","$2,890 ","$60 ","$1,000 ","$1,100 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver Copay 3500 CSR 73","$1,980 ","$650 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360140,"Hometown East Silver Copay 3500",61589ID236,,IDN004,IDS003,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360140-05,"87% AV Level Silver Plan",87.06%,0.865447614,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$200 ","$200 per person | $400 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$200 ","$1,160 ","$1,590 ","$60 ","$300 ","$980 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver Copay 3500 CSR 87","$200 ","$790 ","$570 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360140,"Hometown East Silver Copay 3500",61589ID236,,IDN004,IDS003,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360140-06,"94% AV Level Silver Plan",94.46%,0.938607289,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,400 ","$1400 per person | $2800 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$240 ","$1,160 ","$60 ","$0 ","$680 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver Copay 3500 CSR 94","$0 ","$380 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360141,"CPN North Central Silver Copay 3500",61589ID236,,IDN011,IDS015,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360141-01,"Standard Silver On Exchange Plan",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver Copay 3500","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360141,"CPN North Central Silver Copay 3500",61589ID236,,IDN011,IDS015,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360141-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"CPN North Central Silver Copay 3500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360141,"CPN North Central Silver Copay 3500",61589ID236,,IDN011,IDS015,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360141-03,"Limited Cost Sharing Plan Variation",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver Copay 3500 Tribal","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360141,"CPN North Central Silver Copay 3500",61589ID236,,IDN011,IDS015,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360141-04,"73% AV Level Silver Plan",73.12%,0.71726152,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$1,360 ","$2,890 ","$60 ","$1,000 ","$1,100 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver Copay 3500 CSR 73","$1,980 ","$650 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360141,"CPN North Central Silver Copay 3500",61589ID236,,IDN011,IDS015,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360141-05,"87% AV Level Silver Plan",87.06%,0.865447614,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$200 ","$200 per person | $400 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$200 ","$1,160 ","$1,590 ","$60 ","$300 ","$980 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver Copay 3500 CSR 87","$200 ","$790 ","$570 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360141,"CPN North Central Silver Copay 3500",61589ID236,,IDN011,IDS015,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360141-06,"94% AV Level Silver Plan",94.46%,0.938607289,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,400 ","$1400 per person | $2800 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$240 ","$1,160 ","$60 ","$0 ","$680 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver Copay 3500 CSR 94","$0 ","$380 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360142,"KCN North Silver Copay 3500",61589ID236,,IDN010,IDS013,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360142-01,"Standard Silver On Exchange Plan",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Silver Copay 3500","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360142,"KCN North Silver Copay 3500",61589ID236,,IDN010,IDS013,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360142-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"KCN North Silver Copay 3500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360142,"KCN North Silver Copay 3500",61589ID236,,IDN010,IDS013,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360142-03,"Limited Cost Sharing Plan Variation",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Silver Copay 3500 Tribal","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360142,"KCN North Silver Copay 3500",61589ID236,,IDN010,IDS013,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360142-04,"73% AV Level Silver Plan",73.12%,0.71726152,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$1,360 ","$2,890 ","$60 ","$1,000 ","$1,100 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Silver Copay 3500 CSR 73","$1,980 ","$650 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360142,"KCN North Silver Copay 3500",61589ID236,,IDN010,IDS013,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360142-05,"87% AV Level Silver Plan",87.06%,0.865447614,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$200 ","$200 per person | $400 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$200 ","$1,160 ","$1,590 ","$60 ","$300 ","$980 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Silver Copay 3500 CSR 87","$200 ","$790 ","$570 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360142,"KCN North Silver Copay 3500",61589ID236,,IDN010,IDS013,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360142-06,"94% AV Level Silver Plan",94.46%,0.938607289,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,400 ","$1400 per person | $2800 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$240 ","$1,160 ","$60 ","$0 ","$680 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Silver Copay 3500 CSR 94","$0 ","$380 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360143,"Hometown North Silver Copay 3500",61589ID236,,IDN012,IDS017,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360143-01,"Standard Silver On Exchange Plan",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver Copay 3500","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360143,"Hometown North Silver Copay 3500",61589ID236,,IDN012,IDS017,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360143-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown North Silver Copay 3500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360143,"Hometown North Silver Copay 3500",61589ID236,,IDN012,IDS017,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360143-03,"Limited Cost Sharing Plan Variation",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver Copay 3500 Tribal","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360143,"Hometown North Silver Copay 3500",61589ID236,,IDN012,IDS017,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360143-04,"73% AV Level Silver Plan",73.12%,0.71726152,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$1,360 ","$2,890 ","$60 ","$1,000 ","$1,100 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver Copay 3500 CSR 73","$1,980 ","$650 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360143,"Hometown North Silver Copay 3500",61589ID236,,IDN012,IDS017,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360143-05,"87% AV Level Silver Plan",87.06%,0.865447614,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$200 ","$200 per person | $400 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$200 ","$1,160 ","$1,590 ","$60 ","$300 ","$980 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver Copay 3500 CSR 87","$200 ","$790 ","$570 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360143,"Hometown North Silver Copay 3500",61589ID236,,IDN012,IDS017,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360143-06,"94% AV Level Silver Plan",94.46%,0.938607289,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,400 ","$1400 per person | $2800 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$240 ","$1,160 ","$60 ","$0 ","$680 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver Copay 3500 CSR 94","$0 ","$380 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360145,"IDID Southwest Silver Copay 3500",61589ID236,,IDN008,IDS011,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360145-01,"Standard Silver On Exchange Plan",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver Copay 3500","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360145,"IDID Southwest Silver Copay 3500",61589ID236,,IDN008,IDS011,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360145-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"IDID Southwest Silver Copay 3500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360145,"IDID Southwest Silver Copay 3500",61589ID236,,IDN008,IDS011,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360145-03,"Limited Cost Sharing Plan Variation",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver Copay 3500 Tribal","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360145,"IDID Southwest Silver Copay 3500",61589ID236,,IDN008,IDS011,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360145-04,"73% AV Level Silver Plan",73.12%,0.71726152,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$1,360 ","$2,890 ","$60 ","$1,000 ","$1,100 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver Copay 3500 CSR 73","$1,980 ","$650 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360145,"IDID Southwest Silver Copay 3500",61589ID236,,IDN008,IDS011,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360145-05,"87% AV Level Silver Plan",87.06%,0.865447614,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$200 ","$200 per person | $400 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$200 ","$1,160 ","$1,590 ","$60 ","$300 ","$980 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver Copay 3500 CSR 87","$200 ","$790 ","$570 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360145,"IDID Southwest Silver Copay 3500",61589ID236,,IDN008,IDS011,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360145-06,"94% AV Level Silver Plan",94.46%,0.938607289,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,400 ","$1400 per person | $2800 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$240 ","$1,160 ","$60 ","$0 ","$680 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver Copay 3500 CSR 94","$0 ","$380 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360146,"SLHP Silver Copay CarePoint 3500",61589ID236,,IDN007,IDS009,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360146-01,"Standard Silver On Exchange Plan",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Silver Copay CarePoint 3500","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360146,"SLHP Silver Copay CarePoint 3500",61589ID236,,IDN007,IDS009,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360146-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"SLHP Silver Copay CarePoint 3500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360146,"SLHP Silver Copay CarePoint 3500",61589ID236,,IDN007,IDS009,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360146-03,"Limited Cost Sharing Plan Variation",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Silver Copay CarePoint 3500 Tribal","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360146,"SLHP Silver Copay CarePoint 3500",61589ID236,,IDN007,IDS009,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360146-04,"73% AV Level Silver Plan",73.12%,0.71726152,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$1,360 ","$2,890 ","$60 ","$1,000 ","$1,100 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Silver Copay CarePoint 3500 CSR 73","$1,980 ","$650 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360146,"SLHP Silver Copay CarePoint 3500",61589ID236,,IDN007,IDS009,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360146-05,"87% AV Level Silver Plan",87.06%,0.865447614,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$200 ","$200 per person | $400 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$200 ","$1,160 ","$1,590 ","$60 ","$300 ","$980 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Silver Copay CarePoint 3500 CSR 87","$200 ","$790 ","$570 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360146,"SLHP Silver Copay CarePoint 3500",61589ID236,,IDN007,IDS009,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360146-06,"94% AV Level Silver Plan",94.46%,0.938607289,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,400 ","$1400 per person | $2800 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$240 ","$1,160 ","$60 ","$0 ","$680 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Silver Copay CarePoint 3500 CSR 94","$0 ","$380 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360147,"MVN East Silver Copay Connect  3500",61589ID236,,IDN005,IDS005,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360147-01,"Standard Silver On Exchange Plan",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Copay Connect  3500","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360147,"MVN East Silver Copay Connect  3500",61589ID236,,IDN005,IDS005,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360147-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"MVN East Silver Copay Connect  3500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360147,"MVN East Silver Copay Connect  3500",61589ID236,,IDN005,IDS005,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360147-03,"Limited Cost Sharing Plan Variation",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Copay Connect  3500 Tribal ","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360147,"MVN East Silver Copay Connect  3500",61589ID236,,IDN005,IDS005,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360147-04,"73% AV Level Silver Plan",73.12%,0.71726152,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$1,360 ","$2,890 ","$60 ","$1,000 ","$1,100 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Copay Connect  3500 CSR 73","$1,980 ","$650 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360147,"MVN East Silver Copay Connect  3500",61589ID236,,IDN005,IDS005,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360147-05,"87% AV Level Silver Plan",87.06%,0.865447614,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$200 ","$200 per person | $400 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$200 ","$1,160 ","$1,590 ","$60 ","$300 ","$980 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Copay Connect  3500 CSR 87","$200 ","$790 ","$570 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360147,"MVN East Silver Copay Connect  3500",61589ID236,,IDN005,IDS005,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360147-06,"94% AV Level Silver Plan",94.46%,0.938607289,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,400 ","$1400 per person | $2800 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$240 ","$1,160 ","$60 ","$0 ","$680 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Copay Connect  3500 CSR 94","$0 ","$380 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360148,"PQA Southeast Silver Copay Connect 2500",61589ID236,,IDN006,IDS007,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360148-01,"Standard Silver On Exchange Plan",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Copay Connect 2500","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360148,"PQA Southeast Silver Copay Connect 2500",61589ID236,,IDN006,IDS007,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360148-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"PQA Southeast Silver Copay Connect 2500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360148,"PQA Southeast Silver Copay Connect 2500",61589ID236,,IDN006,IDS007,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360148-03,"Limited Cost Sharing Plan Variation",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Copay Connect 2500 Tribal ","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360148,"PQA Southeast Silver Copay Connect 2500",61589ID236,,IDN006,IDS007,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360148-04,"73% AV Level Silver Plan",73.18%,0.728606907,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,300 ","$7300 per person | $14600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,150 ","$2150 per person | $4300 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,150 ","$1,390 ","$3,760 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Copay Connect 2500 CSR 73","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360148,"PQA Southeast Silver Copay Connect 2500",61589ID236,,IDN006,IDS007,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360148-05,"87% AV Level Silver Plan",87.80%,0.875319599,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$0 ","$890 ","$2,060 ","$60 ","$300 ","$960 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Copay Connect 2500 CSR 87","$0 ","$660 ","$670 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360148,"PQA Southeast Silver Copay Connect 2500",61589ID236,,IDN006,IDS007,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360148-06,"94% AV Level Silver Plan",94.96%,0.945607663,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,250 ","$1250 per person | $2500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$90 ","$1,160 ","$60 ","$0 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"PQA Southeast Silver Copay Connect 2500 CSR 94","$0 ","$320 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360149,"Hometown East Silver Copay 2500",61589ID236,,IDN004,IDS003,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360149-01,"Standard Silver On Exchange Plan",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver Copay 2500","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360149,"Hometown East Silver Copay 2500",61589ID236,,IDN004,IDS003,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360149-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown East Silver Copay 2500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360149,"Hometown East Silver Copay 2500",61589ID236,,IDN004,IDS003,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360149-03,"Limited Cost Sharing Plan Variation",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver Copay 2500 Tribal ","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360149,"Hometown East Silver Copay 2500",61589ID236,,IDN004,IDS003,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360149-04,"73% AV Level Silver Plan",73.18%,0.728606907,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,300 ","$7300 per person | $14600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,150 ","$2150 per person | $4300 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,150 ","$1,390 ","$3,760 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver Copay 2500 CSR 73","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360149,"Hometown East Silver Copay 2500",61589ID236,,IDN004,IDS003,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360149-05,"87% AV Level Silver Plan",87.80%,0.875319599,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$0 ","$890 ","$2,060 ","$60 ","$300 ","$960 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver Copay 2500 CSR 87","$0 ","$660 ","$670 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360149,"Hometown East Silver Copay 2500",61589ID236,,IDN004,IDS003,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360149-06,"94% AV Level Silver Plan",94.96%,0.945607663,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,250 ","$1250 per person | $2500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$90 ","$1,160 ","$60 ","$0 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown East Silver Copay 2500 CSR 94","$0 ","$320 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360150,"CPN North Central Silver Copay 2500",61589ID236,,IDN011,IDS015,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360150-01,"Standard Silver On Exchange Plan",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver Copay 2500","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360150,"CPN North Central Silver Copay 2500",61589ID236,,IDN011,IDS015,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360150-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"CPN North Central Silver Copay 2500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360150,"CPN North Central Silver Copay 2500",61589ID236,,IDN011,IDS015,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360150-03,"Limited Cost Sharing Plan Variation",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver Copay 2500 Tribal ","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360150,"CPN North Central Silver Copay 2500",61589ID236,,IDN011,IDS015,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360150-04,"73% AV Level Silver Plan",73.18%,0.728606907,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,300 ","$7300 per person | $14600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,150 ","$2150 per person | $4300 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,150 ","$1,390 ","$3,760 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver Copay 2500 CSR 73","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360150,"CPN North Central Silver Copay 2500",61589ID236,,IDN011,IDS015,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360150-05,"87% AV Level Silver Plan",87.80%,0.875319599,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$0 ","$890 ","$2,060 ","$60 ","$300 ","$960 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver Copay 2500 CSR 87","$0 ","$660 ","$670 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360150,"CPN North Central Silver Copay 2500",61589ID236,,IDN011,IDS015,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360150-06,"94% AV Level Silver Plan",94.96%,0.945607663,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,250 ","$1250 per person | $2500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$90 ","$1,160 ","$60 ","$0 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"CPN North Central Silver Copay 2500 CSR 94","$0 ","$320 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360151,"KCN North Silver Copay 2500",61589ID236,,IDN010,IDS013,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360151-01,"Standard Silver On Exchange Plan",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Silver Copay 2500","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360151,"KCN North Silver Copay 2500",61589ID236,,IDN010,IDS013,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360151-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"KCN North Silver Copay 2500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360151,"KCN North Silver Copay 2500",61589ID236,,IDN010,IDS013,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360151-03,"Limited Cost Sharing Plan Variation",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Silver Copay 2500 Tribal ","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360151,"KCN North Silver Copay 2500",61589ID236,,IDN010,IDS013,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360151-04,"73% AV Level Silver Plan",73.18%,0.728606907,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,300 ","$7300 per person | $14600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,150 ","$2150 per person | $4300 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,150 ","$1,390 ","$3,760 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Silver Copay 2500 CSR 73","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360151,"KCN North Silver Copay 2500",61589ID236,,IDN010,IDS013,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360151-05,"87% AV Level Silver Plan",87.80%,0.875319599,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$0 ","$890 ","$2,060 ","$60 ","$300 ","$960 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Silver Copay 2500 CSR 87","$0 ","$660 ","$670 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360151,"KCN North Silver Copay 2500",61589ID236,,IDN010,IDS013,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360151-06,"94% AV Level Silver Plan",94.96%,0.945607663,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,250 ","$1250 per person | $2500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$90 ","$1,160 ","$60 ","$0 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"KCN North Silver Copay 2500 CSR 94","$0 ","$320 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360152,"Hometown North Silver Copay 2500",61589ID236,,IDN012,IDS017,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360152-01,"Standard Silver On Exchange Plan",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver Copay 2500","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360152,"Hometown North Silver Copay 2500",61589ID236,,IDN012,IDS017,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360152-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown North Silver Copay 2500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360152,"Hometown North Silver Copay 2500",61589ID236,,IDN012,IDS017,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360152-03,"Limited Cost Sharing Plan Variation",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver Copay 2500 Tribal ","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360152,"Hometown North Silver Copay 2500",61589ID236,,IDN012,IDS017,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360152-04,"73% AV Level Silver Plan",73.18%,0.728606907,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,300 ","$7300 per person | $14600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,150 ","$2150 per person | $4300 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,150 ","$1,390 ","$3,760 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver Copay 2500 CSR 73","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360152,"Hometown North Silver Copay 2500",61589ID236,,IDN012,IDS017,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360152-05,"87% AV Level Silver Plan",87.80%,0.875319599,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$0 ","$890 ","$2,060 ","$60 ","$300 ","$960 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver Copay 2500 CSR 87","$0 ","$660 ","$670 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360152,"Hometown North Silver Copay 2500",61589ID236,,IDN012,IDS017,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360152-06,"94% AV Level Silver Plan",94.96%,0.945607663,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,250 ","$1250 per person | $2500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$90 ","$1,160 ","$60 ","$0 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown North Silver Copay 2500 CSR 94","$0 ","$320 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360154,"IDID Southwest Silver Copay 2500",61589ID236,,IDN008,IDS011,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360154-01,"Standard Silver On Exchange Plan",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver Copay 2500","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360154,"IDID Southwest Silver Copay 2500",61589ID236,,IDN008,IDS011,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360154-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"IDID Southwest Silver Copay 2500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360154,"IDID Southwest Silver Copay 2500",61589ID236,,IDN008,IDS011,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360154-03,"Limited Cost Sharing Plan Variation",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver Copay 2500 Tribal ","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360154,"IDID Southwest Silver Copay 2500",61589ID236,,IDN008,IDS011,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360154-04,"73% AV Level Silver Plan",73.18%,0.728606907,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,300 ","$7300 per person | $14600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,150 ","$2150 per person | $4300 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,150 ","$1,390 ","$3,760 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver Copay 2500 CSR 73","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360154,"IDID Southwest Silver Copay 2500",61589ID236,,IDN008,IDS011,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360154-05,"87% AV Level Silver Plan",87.80%,0.875319599,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$0 ","$890 ","$2,060 ","$60 ","$300 ","$960 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver Copay 2500 CSR 87","$0 ","$660 ","$670 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360154,"IDID Southwest Silver Copay 2500",61589ID236,,IDN008,IDS011,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360154-06,"94% AV Level Silver Plan",94.96%,0.945607663,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,250 ","$1250 per person | $2500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$90 ","$1,160 ","$60 ","$0 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"IDID Southwest Silver Copay 2500 CSR 94","$0 ","$320 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360155,"SLHP Silver Copay CarePoint 2500",61589ID236,,IDN007,IDS009,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360155-01,"Standard Silver On Exchange Plan",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Silver Copay CarePoint 2500","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360155,"SLHP Silver Copay CarePoint 2500",61589ID236,,IDN007,IDS009,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360155-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"SLHP Silver Copay CarePoint 2500 Tribal 0 ","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360155,"SLHP Silver Copay CarePoint 2500",61589ID236,,IDN007,IDS009,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360155-03,"Limited Cost Sharing Plan Variation",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Silver Copay CarePoint 2500 Tribal ","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360155,"SLHP Silver Copay CarePoint 2500",61589ID236,,IDN007,IDS009,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360155-04,"73% AV Level Silver Plan",73.18%,0.728606907,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,300 ","$7300 per person | $14600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,150 ","$2150 per person | $4300 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,150 ","$1,390 ","$3,760 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Silver Copay CarePoint 2500 CSR 73","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360155,"SLHP Silver Copay CarePoint 2500",61589ID236,,IDN007,IDS009,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360155-05,"87% AV Level Silver Plan",87.80%,0.875319599,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$0 ","$890 ","$2,060 ","$60 ","$300 ","$960 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Silver Copay CarePoint 2500 CSR 87","$0 ","$660 ","$670 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360155,"SLHP Silver Copay CarePoint 2500",61589ID236,,IDN007,IDS009,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360155-06,"94% AV Level Silver Plan",94.96%,0.945607663,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,250 ","$1250 per person | $2500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$90 ","$1,160 ","$60 ","$0 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"SLHP Silver Copay CarePoint 2500 CSR 94","$0 ","$320 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360156,"MVN East Silver Copay Connect 2500",61589ID236,,IDN005,IDS005,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360156-01,"Standard Silver On Exchange Plan",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Copay Connect 2500","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360156,"MVN East Silver Copay Connect 2500",61589ID236,,IDN005,IDS005,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360156-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"MVN East Silver Copay Connect 2500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360156,"MVN East Silver Copay Connect 2500",61589ID236,,IDN005,IDS005,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360156-03,"Limited Cost Sharing Plan Variation",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Copay Connect 2500 Tribal ","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360156,"MVN East Silver Copay Connect 2500",61589ID236,,IDN005,IDS005,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360156-04,"73% AV Level Silver Plan",73.18%,0.728606907,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,300 ","$7300 per person | $14600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,150 ","$2150 per person | $4300 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,150 ","$1,390 ","$3,760 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Copay Connect 2500 CSR 73","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360156,"MVN East Silver Copay Connect 2500",61589ID236,,IDN005,IDS005,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360156-05,"87% AV Level Silver Plan",87.80%,0.875319599,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$0 ","$890 ","$2,060 ","$60 ","$300 ","$960 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Copay Connect 2500 CSR 87","$0 ","$660 ","$670 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360156,"MVN East Silver Copay Connect 2500",61589ID236,,IDN005,IDS005,IDF002,Existing,POS,Silver,Yes,Both,No,Yes,"Allergy/Immunology, Audiologist, Bariatrics, Cardiology, Cardiovascular Surgery, Colon and Rectal Surgery, Dermatology, Endocrinology, Gastroenterology, General Surgery, Genetics Specialist, Hand Surgery, Hematology, Infectious Disease, Neonatology, Nephrology, Neurological Surgery, Neurology, Oncology, Ophthalmology, Oral Surgery, Orthopedic, Otolaryngology/ENT, Physical Medicine and Rehabilitation, Plastic Surgery, Podiatrist, Proctology, Psychiatry, Psychologist, Pulmonary Disease, Radiology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery ",,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360156-06,"94% AV Level Silver Plan",94.96%,0.945607663,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,250 ","$1250 per person | $2500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$90 ","$1,160 ","$60 ","$0 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"MVN East Silver Copay Connect 2500 CSR 94","$0 ","$320 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360157,"Hometown Southwest Catastrophic 9450",61589ID236,,IDN013,IDS019,IDF003,New,POS,Catastrophic,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,3,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360157-01,"Standard Catastrophic On Exchange Plan",,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",0.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$9,450 ","$0 ","$0 ","$60 ","$4,700 ","$90 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Catastrophic 9450","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360158,"Hometown Southwest Bronze HSA 6250",61589ID236,,IDN013,IDS019,IDF006,New,POS,"Expanded Bronze",Yes,Both,No,No,,,Yes,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360158-01,"Standard Bronze On Exchange Plan",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Bronze HSA 6250","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360158,"Hometown Southwest Bronze HSA 6250",61589ID236,,IDN013,IDS019,IDF006,New,POS,"Expanded Bronze",Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360158-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown Southwest Bronze 6250 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360158,"Hometown Southwest Bronze HSA 6250",61589ID236,,IDN013,IDS019,IDF006,New,POS,"Expanded Bronze",Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360158-03,"Limited Cost Sharing Plan Variation",64.62%,0.646119468,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,250 ","$6250 per person | $12500 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$6,250 ","$0 ","$1,250 ","$60 ","$4,790 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Bronze 6250 Tribal ","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360159,"Hometown Southwest Bronze 7500",61589ID236,,IDN013,IDS019,IDF004,New,POS,"Expanded Bronze",Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360159-01,"Standard Bronze On Exchange Plan",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Bronze 7500","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360159,"Hometown Southwest Bronze 7500",61589ID236,,IDN013,IDS019,IDF004,New,POS,"Expanded Bronze",Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360159-02,"Zero Cost Sharing Plan Variation",100.00%,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown Southwest Bronze 7500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360159,"Hometown Southwest Bronze 7500",61589ID236,,IDN013,IDS019,IDF004,New,POS,"Expanded Bronze",Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360159-03,"Limited Cost Sharing Plan Variation",64.74%,0.63668814,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$1,060 ","$890 ","$60 ","$3,130 ","$880 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Bronze 7500  Tribal ","$2,450 ","$290 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360160,"Hometown Southwest Silver Copay 3500",61589ID236,,IDN013,IDS019,IDF002,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360160-01,"Standard Silver On Exchange Plan",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver Copay 3500","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360160,"Hometown Southwest Silver Copay 3500",61589ID236,,IDN013,IDS019,IDF002,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360160-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown Southwest Silver Copay 3500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360160,"Hometown Southwest Silver Copay 3500",61589ID236,,IDN013,IDS019,IDF002,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360160-03,"Limited Cost Sharing Plan Variation",70.61%,0.687343295,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$3500 per person | $7000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,500 ","$1,360 ","$3,790 ","$60 ","$1,000 ","$1,130 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver Copay 3500 Tribal ","$1,980 ","$670 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360160,"Hometown Southwest Silver Copay 3500",61589ID236,,IDN013,IDS019,IDF002,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360160-04,"73% AV Level Silver Plan",73.12%,0.71726152,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$3,000 ","$1,360 ","$2,890 ","$60 ","$1,000 ","$1,100 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver Copay 3500 CSR 73","$1,980 ","$650 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360160,"Hometown Southwest Silver Copay 3500",61589ID236,,IDN013,IDS019,IDF002,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360160-05,"87% AV Level Silver Plan",87.06%,0.865447614,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$200 ","$200 per person | $400 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$200 ","$1,160 ","$1,590 ","$60 ","$300 ","$980 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver Copay 3500 CSR 87","$200 ","$790 ","$570 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360160,"Hometown Southwest Silver Copay 3500",61589ID236,,IDN013,IDS019,IDF002,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360160-06,"94% AV Level Silver Plan",94.46%,0.938607289,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,400 ","$1400 per person | $2800 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$240 ","$1,160 ","$60 ","$0 ","$680 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver Copay 3500 CSR 94","$0 ","$380 ","$500 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360161,"Hometown Southwest Silver 5500",61589ID236,,IDN013,IDS019,IDF001,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360161-01,"Standard Silver On Exchange Plan",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver 5500","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360161,"Hometown Southwest Silver 5500",61589ID236,,IDN013,IDS019,IDF001,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360161-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown Southwest Silver 5500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360161,"Hometown Southwest Silver 5500",61589ID236,,IDN013,IDS019,IDF001,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360161-03,"Limited Cost Sharing Plan Variation",70.04%,0.695389571,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$5,500 ","$10 ","$2,830 ","$60 ","$1,120 ","$900 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver 5500 Tribal ","$2,450 ","$220 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360161,"Hometown Southwest Silver 5500",61589ID236,,IDN013,IDS019,IDF001,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360161-04,"73% AV Level Silver Plan",73.85%,0.733866356,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,250 ","$7250 per person | $14500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$4,750 ","$4750 per person | $9500 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$4,750 ","$10 ","$2,340 ","$60 ","$1,120 ","$870 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver 5500 CSR 73","$2,450 ","$170 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360161,"Hometown Southwest Silver 5500",61589ID236,,IDN013,IDS019,IDF001,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360161-05,"87% AV Level Silver Plan",87.20%,0.867604964,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,700 ","$2700 per person | $5400 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$650 ","$650 per person | $1300 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$250 ","$250 per person | per group not applicable",,,,,,,,,,,"$650 ","$10 ","$2,040 ","$60 ","$370 ","$950 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver 5500 CSR 87","$650 ","$510 ","$290 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360161,"Hometown Southwest Silver 5500",61589ID236,,IDN013,IDS019,IDF001,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360161-06,"94% AV Level Silver Plan",94.09%,0.936850326,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,300 ","$1300 per person | $2600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",20.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | per group not applicable",,,,,,,,,,,"$0 ","$10 ","$1,290 ","$60 ","$100 ","$810 ","$20 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver 5500 CSR 94","$0 ","$270 ","$440 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360162,"Hometown Southwest Silver Copay 2500",61589ID236,,IDN013,IDS019,IDF002,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360162-01,"Standard Silver On Exchange Plan",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver Copay 2500","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360162,"Hometown Southwest Silver Copay 2500",61589ID236,,IDN013,IDS019,IDF002,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360162-02,"Zero Cost Sharing Plan Variation",100.00%,1,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,"$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Hometown Southwest Silver Copay 2500 Tribal 0","$0 ","$0 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360162,"Hometown Southwest Silver Copay 2500",61589ID236,,IDN013,IDS019,IDF002,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360162-03,"Limited Cost Sharing Plan Variation",70.53%,0.702259592,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,100 ","$9100 per person | $18200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$2500 per person | $5000 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,500 ","$1,430 ","$4,290 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver Copay 2500 Tribal ","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360162,"Hometown Southwest Silver Copay 2500",61589ID236,,IDN013,IDS019,IDF002,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360162-04,"73% AV Level Silver Plan",73.18%,0.728606907,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,300 ","$7300 per person | $14600 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$2,150 ","$2150 per person | $4300 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",50.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | per group not applicable",,,,,,,,,,,"$2,150 ","$1,390 ","$3,760 ","$60 ","$1,000 ","$1,090 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver Copay 2500 CSR 73","$1,980 ","$580 ","$0 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360162,"Hometown Southwest Silver Copay 2500",61589ID236,,IDN013,IDS019,IDF002,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360162-05,"87% AV Level Silver Plan",87.80%,0.875319599,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,950 ","$2950 per person | $5900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",40.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$300 ","$300 per person | per group not applicable",,,,,,,,,,,"$0 ","$890 ","$2,060 ","$60 ","$300 ","$960 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver Copay 2500 CSR 87","$0 ","$660 ","$670 ","$0 "
2024,ID,,61589,SERFF,1,2/12/2024,,Individual,No,,61589ID2360162,"Hometown Southwest Silver Copay 2500",61589ID236,,IDN013,IDS019,IDF002,New,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"The benefits available under this contract are also available to members traveling or living outside the United States. The inpatient notification and prior authorization requirements will apply.",Yes,"In these situations, the enrollee may be responsible for the difference between the amount that the non-participating healthcare provider bills and the payment BCI will make for the covered services. Except as provided by the federal No Surprises Act.",Yes,,,,,61589ID2360162-06,"94% AV Level Silver Plan",94.96%,0.945607663,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,250 ","$1250 per person | $2500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",30.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","Not Applicable","per person not applicable | per group not applicable",30.00%,,,,"Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | per group not applicable",,,,,,,,,,,"$0 ","$90 ","$1,160 ","$60 ","$0 ","$600 ","$0 ","$20 ",100%,"Not Applicable",No,"Hometown Southwest Silver Copay 2500 CSR 94","$0 ","$320 ","$500 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010007,"Moda Select Gold 1000 Separate Rx + Vision Exam",80588ID001,,IDN001,IDS001,IDF001,Existing,POS,Gold,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010007-01,"Standard Gold On Exchange Plan",80.46%,,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$80,000 ","$80000 per person | $160000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | $2000 per group",15.00%,,,,"$2,000 ","$2000 per person | $4000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1000 per group",15.00%,,,,"$1,000 ","$1000 per person | $2000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$1,000 ","$10 ","$1,700 ","$50 ","$900 ","$200 ","$1,100 ","$20 ",99%,"Not Applicable",No,"Moda Select Gold 1000 Separate Rx + Vision Exam","$1,000 ","$100 ","$200 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010007,"Moda Select Gold 1000 Separate Rx + Vision Exam",80588ID001,,IDN001,IDS001,IDF001,Existing,POS,Gold,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010007-02,"Zero Cost Sharing Plan Variation",100.00%,,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$0 ","$50 ","$0 ","$0 ","$0 ","$20 ",99%,"Not Applicable",No,"Moda Select Gold 1000 Separate Rx + Vision Exam","$0 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010007,"Moda Select Gold 1000 Separate Rx + Vision Exam",80588ID001,,IDN001,IDS001,IDF001,Existing,POS,Gold,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010007-03,"Limited Cost Sharing Plan Variation",80.46%,,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,000 ","$8000 per person | $16000 per group",,,"$80,000 ","$80000 per person | $160000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$1000 per person | $2000 per group",15.00%,,,,"$2,000 ","$2000 per person | $4000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$500 per person | $1000 per group",15.00%,,,,"$1,000 ","$1000 per person | $2000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$0 ","$50 ","$0 ","$0 ","$0 ","$20 ",99%,"Not Applicable",No,"Moda Select Gold 1000 Separate Rx + Vision Exam","$0 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010008,"Moda Select Gold 2200 + Vision Exam",80588ID001,,IDN001,IDS001,IDF002,Existing,POS,Gold,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010008-01,"Standard Gold On Exchange Plan",78.42%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,600 ","$7600 per person | $15200 per group",,,"$76,000 ","$76000 per person | $152000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$2,200 ","$2200 per person | $4400 per group",10.00%,,,,"$4,400 ","$4400 per person | $8800 per group","Not Applicable","per person not applicable | per group not applicable","$2,200 ","$10 ","$1,000 ","$50 ","$400 ","$100 ","$1,200 ","$20 ",99%,"Not Applicable",No,"Moda Select Gold 2200 + Vision Exam","$2,200 ","$100 ","$10 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010008,"Moda Select Gold 2200 + Vision Exam",80588ID001,,IDN001,IDS001,IDF002,Existing,POS,Gold,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010008-02,"Zero Cost Sharing Plan Variation",100.00%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$50 ","$0 ","$0 ","$0 ","$20 ",99%,"Not Applicable",No,"Moda Select Gold 2200 + Vision Exam","$0 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010008,"Moda Select Gold 2200 + Vision Exam",80588ID001,,IDN001,IDS001,IDF002,Existing,POS,Gold,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010008-03,"Limited Cost Sharing Plan Variation",78.42%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,600 ","$7600 per person | $15200 per group",,,"$76,000 ","$76000 per person | $152000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$2,200 ","$2200 per person | $4400 per group",10.00%,,,,"$4,400 ","$4400 per person | $8800 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$50 ","$0 ","$0 ","$0 ","$20 ",99%,"Not Applicable",No,"Moda Select Gold 2200 + Vision Exam","$0 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010009,"Moda Select Silver 3000 Separate Rx + Vision Exam",80588ID001,,IDN001,IDS001,IDF003,Existing,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010009-01,"Standard Silver On Exchange Plan",71.42%,,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,250 ","$8250 per person | $16500 per group",,,"$87,000 ","$87000 per person | $174000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",35.00%,,,,"$6,000 ","$6000 per person | $12000 per group","Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | $3000 per group",35.00%,,,,"$3,000 ","$3000 per person | $6000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$3,000 ","$10 ","$3,300 ","$50 ","$1,900 ","$300 ","$1,100 ","$20 ",99%,"Not Applicable",No,"Moda Select Silver 3000 Separate Rx + Vision Exam","$2,300 ","$200 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010009,"Moda Select Silver 3000 Separate Rx + Vision Exam",80588ID001,,IDN001,IDS001,IDF003,Existing,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010009-02,"Zero Cost Sharing Plan Variation",100.00%,,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$0 ","$50 ","$0 ","$0 ","$0 ","$20 ",99%,"Not Applicable",No,"Moda Select Silver 3000 Separate Rx + Vision Exam","$0 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010009,"Moda Select Silver 3000 Separate Rx + Vision Exam",80588ID001,,IDN001,IDS001,IDF003,Existing,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010009-03,"Limited Cost Sharing Plan Variation",71.42%,,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,250 ","$8250 per person | $16500 per group",,,"$87,000 ","$87000 per person | $174000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$3000 per person | $6000 per group",35.00%,,,,"$6,000 ","$6000 per person | $12000 per group","Not Applicable","per person not applicable | per group not applicable","$1,500 ","$1500 per person | $3000 per group",35.00%,,,,"$3,000 ","$3000 per person | $6000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$0 ","$0 ","$0 ","$50 ","$0 ","$0 ","$0 ","$20 ",99%,"Not Applicable",No,"Moda Select Silver 3000 Separate Rx + Vision Exam","$0 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010009,"Moda Select Silver 3000 Separate Rx + Vision Exam",80588ID001,,IDN001,IDS001,IDF003,Existing,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010009-04,"73% AV Level Silver Plan",73.73%,,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,750 ","$6750 per person | $13500 per group",,,"$67,500 ","$67500 per person | $135000 per group","Not Applicable","per person not applicable | per group not applicable","$2,750 ","$2750 per person | $5500 per group",35.00%,,,,"$5,500 ","$5500 per person | $11000 per group","Not Applicable","per person not applicable | per group not applicable","$1,250 ","$1250 per person | $2500 per group",35.00%,,,,"$2,500 ","$2500 per person | $5000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$2,750 ","$10 ","$3,400 ","$50 ","$1,600 ","$300 ","$1,200 ","$20 ",99%,"Not Applicable",No,"Moda Select Silver 3000 Separate Rx + Vision Exam","$2,300 ","$200 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010009,"Moda Select Silver 3000 Separate Rx + Vision Exam",80588ID001,,IDN001,IDS001,IDF003,Existing,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010009-05,"87% AV Level Silver Plan",87.61%,,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,000 ","$2000 per person | $4000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable","$750 ","$750 per person | $1500 per group",35.00%,,,,"$1,500 ","$1500 per person | $3000 per group","Not Applicable","per person not applicable | per group not applicable","$375 ","$375 per person | $750 per group",35.00%,,,,"$750 ","$750 per person | $1500 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$750 ","$0 ","$1,250 ","$50 ","$700 ","$200 ","$1,100 ","$20 ",99%,"Not Applicable",No,"Moda Select Silver 3000 Separate Rx + Vision Exam","$750 ","$100 ","$600 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010009,"Moda Select Silver 3000 Separate Rx + Vision Exam",80588ID001,,IDN001,IDS001,IDF003,Existing,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010009-06,"94% AV Level Silver Plan",94.22%,,No,Yes,No,100%,,,,,,,,,,,,,,,,,,"$750 ","$750 per person | $1500 per group",,,"$7,500 ","$7500 per person | $15000 per group","Not Applicable","per person not applicable | per group not applicable","$100 ","$100 per person | $200 per group",35.00%,,,,"$200 ","$200 per person | $400 per group","Not Applicable","per person not applicable | per group not applicable","$50 ","$50 per person | $100 per group",35.00%,,,,"$100 ","$100 per person | $200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,"$100 ","$0 ","$650 ","$50 ","$100 ","$60 ","$500 ","$20 ",99%,"Not Applicable",No,"Moda Select Silver 3000 Separate Rx + Vision Exam","$100 ","$10 ","$600 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010010,"Moda Select Silver 6400 + Vision Exam",80588ID001,,IDN001,IDS001,IDF004,Existing,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010010-01,"Standard Silver On Exchange Plan",71.20%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,350 ","$7350 per person | $14700 per group",,,"$73,500 ","$73500 per person | $147000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,400 ","$6400 per person | $12800 per group",35.00%,,,,"$12,800 ","$12800 per person | $25600 per group","Not Applicable","per person not applicable | per group not applicable","$6,400 ","$0 ","$950 ","$50 ","$400 ","$300 ","$1,700 ","$20 ",99%,"Not Applicable",No,"Moda Select Silver 6400 + Vision Exam","$2,300 ","$200 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010010,"Moda Select Silver 6400 + Vision Exam",80588ID001,,IDN001,IDS001,IDF004,Existing,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010010-02,"Zero Cost Sharing Plan Variation",100.00%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$50 ","$0 ","$0 ","$0 ","$20 ",99%,"Not Applicable",No,"Moda Select Silver 6400 + Vision Exam","$0 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010010,"Moda Select Silver 6400 + Vision Exam",80588ID001,,IDN001,IDS001,IDF004,Existing,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010010-03,"Limited Cost Sharing Plan Variation",71.20%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,350 ","$7350 per person | $14700 per group",,,"$73,500 ","$73500 per person | $147000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,400 ","$6400 per person | $12800 per group",35.00%,,,,"$12,800 ","$12800 per person | $25600 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$50 ","$0 ","$0 ","$0 ","$20 ",99%,"Not Applicable",No,"Moda Select Silver 6400 + Vision Exam","$0 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010010,"Moda Select Silver 6400 + Vision Exam",80588ID001,,IDN001,IDS001,IDF004,Existing,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010010-04,"73% AV Level Silver Plan",73.88%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,350 ","$6350 per person | $12700 per group",,,"$63,500 ","$63500 per person | $127000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$2,500 ","$2500 per person | $5000 per group",35.00%,,,,"$5,000 ","$5000 per person | $10000 per group","Not Applicable","per person not applicable | per group not applicable","$2,500 ","$10 ","$3,500 ","$50 ","$400 ","$300 ","$1,700 ","$20 ",99%,"Not Applicable",No,"Moda Select Silver 6400 + Vision Exam","$2,300 ","$200 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010010,"Moda Select Silver 6400 + Vision Exam",80588ID001,,IDN001,IDS001,IDF004,Existing,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010010-05,"87% AV Level Silver Plan",87.67%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,000 ","$2000 per person | $4000 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$750 ","$750 per person | $1500 per group",35.00%,,,,"$1,500 ","$1500 per person | $3000 per group","Not Applicable","per person not applicable | per group not applicable","$750 ","$0 ","$1,250 ","$50 ","$400 ","$200 ","$1,400 ","$20 ",99%,"Not Applicable",No,"Moda Select Silver 6400 + Vision Exam","$750 ","$100 ","$600 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010010,"Moda Select Silver 6400 + Vision Exam",80588ID001,,IDN001,IDS001,IDF004,Existing,POS,Silver,Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010010-06,"94% AV Level Silver Plan",94.26%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$750 ","$750 per person | $1500 per group",,,"$7,500 ","$7500 per person | $15000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$100 ","$100 per person | $200 per group",35.00%,,,,"$200 ","$200 per person | $400 per group","Not Applicable","per person not applicable | per group not applicable","$100 ","$0 ","$650 ","$50 ","$100 ","$50 ","$600 ","$20 ",99%,"Not Applicable",No,"Moda Select Silver 6400 + Vision Exam","$100 ","$10 ","$600 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010011,"Moda Select Bronze 8900 + Vision Exam",80588ID001,,IDN001,IDS001,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010011-01,"Standard Bronze On Exchange Plan",64.88%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",10.00%,,,,"$17,800 ","$17800 per person | $35600 per group","Not Applicable","per person not applicable | per group not applicable","$8,900 ","$10 ","$0 ","$50 ","$4,500 ","$400 ","$0 ","$20 ",99%,"Not Applicable",No,"Moda Select Bronze 8900 + Vision Exam","$2,300 ","$300 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010011,"Moda Select Bronze 8900 + Vision Exam",80588ID001,,IDN001,IDS001,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010011-02,"Zero Cost Sharing Plan Variation",100.00%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$50 ","$0 ","$0 ","$0 ","$20 ",99%,"Not Applicable",No,"Moda Select Bronze 8900 + Vision Exam","$0 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010011,"Moda Select Bronze 8900 + Vision Exam",80588ID001,,IDN001,IDS001,IDF004,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010011-03,"Limited Cost Sharing Plan Variation",64.88%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",10.00%,,,,"$17,800 ","$17800 per person | $35600 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$50 ","$0 ","$0 ","$0 ","$20 ",99%,"Not Applicable",No,"Moda Select Bronze 8900 + Vision Exam","$0 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010012,"Moda Select Bronze HSA 7500",80588ID001,,IDN001,IDS001,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,Yes,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010012-01,"Standard Bronze On Exchange Plan",63.96%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$75,000 ","$75000 per person | $150000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$0 ","$0 ","$50 ","$5,300 ","$0 ","$0 ","$20 ",99%,"Not Applicable",No,"Moda Select Bronze HSA 7500","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010012,"Moda Select Bronze HSA 7500",80588ID001,,IDN001,IDS001,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010012-02,"Zero Cost Sharing Plan Variation",100.00%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$50 ","$0 ","$0 ","$0 ","$20 ",99%,"Not Applicable",No,"Moda Select Bronze 7500","$0 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,Individual,No,,80588ID0010012,"Moda Select Bronze HSA 7500",80588ID001,,IDN001,IDS001,IDF006,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO",No,,,,,80588ID0010012-03,"Limited Cost Sharing Plan Variation",63.96%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",,,"$75,000 ","$75000 per person | $150000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",0.00%,,,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$50 ","$0 ","$0 ","$0 ","$20 ",99%,"Not Applicable",No,"Moda Select Bronze 7500","$0 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020017,"Moda Select Gold 500",80588ID002,,IDN001,IDS001,IDF008,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,3,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020017-01,"Standard Gold On Exchange Plan",80.75%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,150 ","$8150 per person | $16300 per group",,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$500 ","$500 per person | $1000 per group",30.00%,,,,"$1,500 ","$1500 per person | $3000 per group","Not Applicable","per person not applicable | per group not applicable","$500 ","$10 ","$3,600 ","$50 ","$200 ","$1,100 ","$40 ","$20 ",,,No,"Moda Select Gold 500","$500 ","$500 ","$400 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020018,"Moda Select Gold 1000",80588ID002,,IDN001,IDS001,IDF008,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,3,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020018-01,"Standard Gold On Exchange Plan",80.41%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,150 ","$8150 per person | $16300 per group",,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",25.00%,,,,"$3,000 ","$3000 per person | $6000 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$10 ","$2,900 ","$50 ","$200 ","$1,100 ","$30 ","$20 ",,,No,"Moda Select Gold 1000","$1,000 ","$500 ","$200 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020019,"Moda Select Gold 1500",80588ID002,,IDN001,IDS001,IDF008,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,3,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020019-01,"Standard Gold On Exchange Plan",80.59%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$1,500 ","$1500 per person | $3000 per group",20.00%,,,,"$4,500 ","$4500 per person | $9000 per group","Not Applicable","per person not applicable | per group not applicable","$1,500 ","$10 ","$2,200 ","$50 ","$200 ","$1,100 ","$20 ","$20 ",,,No,"Moda Select Gold 1500","$1,500 ","$300 ","$100 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020020,"Moda Select Gold 2000",80588ID002,,IDN001,IDS001,IDF008,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,3,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020020-01,"Standard Gold On Exchange Plan",80.79%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,000 ","$6000 per person | $12000 per group",,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$2,000 ","$2000 per person | $4000 per group",20.00%,,,,"$6,000 ","$6000 per person | $12000 per group","Not Applicable","per person not applicable | per group not applicable","$2,000 ","$10 ","$2,100 ","$50 ","$200 ","$1,100 ","$20 ","$20 ",,,No,"Moda Select Gold 2000","$2,000 ","$100 ","$70 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020021,"Moda Select Gold 3000",80588ID002,,IDN001,IDS001,IDF008,Existing,POS,Gold,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,3,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020021-01,"Standard Gold On Exchange Plan",81.64%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,000 ","$5000 per person | $10000 per group",,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,000 ","$3000 per person | $6000 per group",20.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","$3,000 ","$10 ","$1,900 ","$50 ","$200 ","$1,100 ","$20 ","$20 ",,,No,"Moda Select Gold 3000","$2,200 ","$100 ","$30 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020022,"Moda Select Silver 3500",80588ID002,,IDN001,IDS001,IDF009,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,3,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020022-01,"Standard Silver On Exchange Plan",71.07%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,550 ","$8550 per person | $17100 per group",,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,500 ","$3500 per person | $6000 per group",40.00%,,,,"$5,000 ","$5000 per person | $10000 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$10 ","$3,600 ","$50 ","$200 ","$1,900 ","$50 ","$20 ",,,No,"Moda Select Silver 3500","$2,200 ","$300 ","$70 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020023,"Moda Select Silver 4500",80588ID002,,IDN001,IDS001,IDF009,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,3,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020023-01,"Standard Silver On Exchange Plan",71.33%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$4,500 ","$4500 per person | $9000 per group",30.00%,,,,"$13,500 ","$13500 per person | $27000 per group","Not Applicable","per person not applicable | per group not applicable","$4,500 ","$10 ","$2,400 ","$50 ","$200 ","$1,900 ","$40 ","$20 ",,,No,"Moda Select Silver 4500","$2,200 ","$200 ","$50 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020024,"Moda Select Silver 5000",80588ID002,,IDN001,IDS001,IDF009,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,3,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020024-01,"Standard Silver On Exchange Plan",71.33%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,000 ","$5000 per person | $10000 per group",30.00%,,,,"$15,000 ","$15000 per person | $30000 per group","Not Applicable","per person not applicable | per group not applicable","$5,000 ","$10 ","$2,300 ","$50 ","$200 ","$1,900 ","$40 ","$20 ",,,No,"Moda Select Silver 5000","$2,200 ","$200 ","$50 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020025,"Moda Select Silver 6000",80588ID002,,IDN001,IDS001,IDF009,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,3,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020025-01,"Standard Silver On Exchange Plan",71.33%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,900 ","$8900 per person | $17800 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,000 ","$6000 per person | $12000 per group",30.00%,,,,"$18,000 ","$18000 per person | $36000 per group","Not Applicable","per person not applicable | per group not applicable","$6,000 ","$10 ","$2,000 ","$50 ","$200 ","$1,900 ","$40 ","$20 ",,,No,"Moda Select Silver 6000","$2,200 ","$200 ","$50 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020026,"Moda Select Silver 6500",80588ID002,,IDN001,IDS001,IDF009,Existing,POS,Silver,Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,3,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020026-01,"Standard Silver On Exchange Plan",71.53%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,750 ","$8750 per person | $17500 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",30.00%,,,,"$16,300 ","$16300 per person | $32600 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$10 ","$1,800 ","$50 ","$200 ","$1,900 ","$40 ","$20 ",,,No,"Moda Select Silver 6500","$2,200 ","$200 ","$50 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020027,"Moda Select Bronze 7500",80588ID002,,IDN001,IDS001,IDF009,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,3,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020027-01,"Standard Bronze On Exchange Plan",65.00%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,200 ","$9200 per person | $18400 per group",,,"$20,000 ","$20000 per person | $40000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,500 ","$7500 per person | $15000 per group",40.00%,,,,"$17,100 ","$17100 per person | $34200 per group","Not Applicable","per person not applicable | per group not applicable","$7,500 ","$0 ","$1,700 ","$50 ","$400 ","$2,100 ","$0 ","$20 ",,,No,"Moda Select Bronze 7500","$2,300 ","$400 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020028,"Moda Select Bronze 8550",80588ID002,,IDN001,IDS001,IDF005,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,No,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,3,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020028-01,"Standard Bronze On Exchange Plan",64.65%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,550 ","$8550 per person | $17100 per group",,,"$17,100 ","$17100 per person | $34200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$8,550 ","$8550 per person | $17100 per group",0.00%,,,,"$17,100 ","$17100 per person | $34200 per group","Not Applicable","per person not applicable | per group not applicable","$8,550 ","$0 ","$0 ","$50 ","$5,300 ","$0 ","$0 ","$20 ",,,No,"Moda Select Bronze 8550","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020029,"Moda Select Gold HDHP 3200",80588ID002,,IDN001,IDS001,IDF005,Existing,POS,Gold,Yes,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020029-01,"Standard Gold On Exchange Plan",80.09%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,200 ","$3200 per person | $6400 per group",,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,200 ","$3200 per person | $6400 per group",0.00%,,,,"$9,000 ","$9000 per person | $18000 per group","Not Applicable","per person not applicable | per group not applicable","$3,200 ","$0 ","$0 ","$50 ","$3,200 ","$0 ","$0 ","$20 ",,,No,"Moda Select Gold HDHP 3200","$3,200 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020030,"Moda Select Silver HDHP 2800",80588ID002,,IDN001,IDS001,IDF010,Existing,POS,Silver,Yes,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020030-01,"Standard Silver On Exchange Plan",71.26%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,750 ","$5750 per person | $11150 per group",,,"$10,000 ","$10000 per person | $20000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$2,800 ","per person not applicable | $5600 per group",30.00%,,,,"$8,400 ","$8400 per person | $16800 per group","Not Applicable","per person not applicable | per group not applicable","$2,800 ","$0 ","$2,900 ","$50 ","$2,800 ","$800 ","$100 ","$20 ",,,No,"Moda Select Silver HDHP 2800","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020031,"Moda Select Silver HDHP 5200",80588ID002,,IDN001,IDS001,IDF005,Existing,POS,Silver,Yes,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020031-01,"Standard Silver On Exchange Plan",71.62%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$5,200 ","$5200 per person | $10400 per group",,,"$15,600 ","$15600 per person | $31200 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,200 ","$5200 per person | $10400 per group",0.00%,,,,"$15,600 ","$15600 per person | $31200 per group","Not Applicable","per person not applicable | per group not applicable","$5,200 ","$0 ","$0 ","$50 ","$5,200 ","$0 ","$0 ","$20 ",,,No,"Moda Select Silver HDHP 5200","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,80588,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,80588ID0020032,"Moda Select Bronze HDHP 7100",80588ID002,,IDN001,IDS001,IDF005,Existing,POS,"Expanded Bronze",Yes,Both,No,No,,,Yes,No,,"Allows Adult and Child-Only",,Yes,"Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,Yes,"Emergency care only",Yes,"All covered services for out of service area employees and dependents and emergency care only for out of service area travel",Yes,,,,,80588ID0020032-01,"Standard Bronze On Exchange Plan",64.83%,,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,100 ","$7100 per person | $14200 per group",,,"$21,300 ","$21300 per person | $42600 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,100 ","$7100 per person | $14200 per group",0.00%,,,,"$21,300 ","$21300 per person | $42600 per group","Not Applicable","per person not applicable | per group not applicable","$7,100 ","$0 ","$0 ","$50 ","$5,300 ","$0 ","$0 ","$20 ",,,No,"Moda Select Bronze HDHP 7100","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010001,"Gold 1",91278ID001,,IDN001,IDS001,IDF001,Existing,HMO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010001-01,"Standard Gold On Exchange Plan",,0.783632282,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,100 ","$8100 per person | $16200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$1,550 ","$1550 per person | $3100 per group",25.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$1,550 ","$300 ","$2,500 ","$0 ","$1,550 ","$900 ","$100 ","$0 ",100%,"Not Applicable",No,"Gold 1","$1,550 ","$200 ","$40 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010001,"Gold 1",91278ID001,,IDN001,IDS001,IDF001,Existing,HMO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010001-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Gold 1 Zero","$0 ","$0 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010001,"Gold 1",91278ID001,,IDN001,IDS001,IDF001,Existing,HMO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010001-03,"Limited Cost Sharing Plan Variation",,0.783632282,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,100 ","$8100 per person | $16200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$1,550 ","$1550 per person | $3100 per group",25.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$1,550 ","$300 ","$2,500 ","$0 ","$1,550 ","$900 ","$100 ","$0 ",100%,"Not Applicable",No,"Gold 1 LCS","$1,550 ","$200 ","$40 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010002,"Silver 1 ",91278ID001,,IDN001,IDS001,IDF002,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010002-01,"Standard Silver On Exchange Plan",,0.70017959,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,850 ","$7850 per person | $15700 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,000 ","$5000 per person | $10000 per group",35.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$5,000 ","$800 ","$2,100 ","$0 ","$3,900 ","$700 ","$0 ","$0 ",100%,"Not Applicable",No,"Silver 1 250","$1,600 ","$400 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010002,"Silver 1 ",91278ID001,,IDN001,IDS001,IDF002,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010002-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Silver 1 Zero","$0 ","$0 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010002,"Silver 1 ",91278ID001,,IDN001,IDS001,IDF002,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010002-03,"Limited Cost Sharing Plan Variation",,0.70017959,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,850 ","$7850 per person | $15700 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,000 ","$5000 per person | $10000 per group",35.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$5,000 ","$800 ","$2,100 ","$0 ","$3,900 ","$700 ","$0 ","$0 ",100%,"Not Applicable",No,"Silver 1 LCS","$1,600 ","$400 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010002,"Silver 1 ",91278ID001,,IDN001,IDS001,IDF002,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010002-04,"73% AV Level Silver Plan",,0.73056813,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,775 ","$6775 per person | $13550 per group",,,"$75,500 ","$75500 per person | $151000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,500 ","$3500 per person | $7000 per group",35.00%,,,,"$15,100 ","$15100 per person | $30200 per group","Not Applicable","per person not applicable | per group not applicable","$3,500 ","$800 ","$2,500 ","$0 ","$3,500 ","$800 ","$20 ","$0 ",100%,"Not Applicable",No,"Silver 1 200","$1,600 ","$400 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010002,"Silver 1 ",91278ID001,,IDN001,IDS001,IDF002,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010002-05,"87% AV Level Silver Plan",,0.870156555,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,750 ","$2750 per person | $5500 per group",,,"$31,500 ","$31500 per person | $63000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$700 ","$700 per person | $1400 per group",25.00%,,,,"$6,300 ","$6300 per person | $12600 per group","Not Applicable","per person not applicable | per group not applicable","$700 ","$600 ","$1,500 ","$0 ","$700 ","$1,200 ","$20 ","$0 ",100%,"Not Applicable",No,"Silver 1 150","$700 ","$300 ","$200 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010002,"Silver 1 ",91278ID001,,IDN001,IDS001,IDF002,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010002-06,"94% AV Level Silver Plan",,0.942686198,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,650 ","$1650 per person | $3300 per group",,,"$31,500 ","$31500 per person | $63000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",20.00%,,,,"$6,300 ","$6300 per person | $12600 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$300 ","$1,400 ","$0 ","$0 ","$500 ","$200 ","$0 ",100%,"Not Applicable",No,"Silver 1 100","$0 ","$100 ","$300 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010009,"Silver 12 with First 4 Primary Care Visits Free",91278ID001,,IDN001,IDS001,IDF003,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,4,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010009-01,"Standard Silver On Exchange Plan",,0.702139028,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,000 ","$60 ","$1,100 ","$0 ","$900 ","$1,800 ","$0 ","$0 ",100%,"Not Applicable",No,"Silver 12 250 with First 4 Primary Care Visits Free","$2,100 ","$200 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010009,"Silver 12 with First 4 Primary Care Visits Free",91278ID001,,IDN001,IDS001,IDF003,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010009-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"Silver 12 Zero ","$0 ","$0 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010009,"Silver 12 with First 4 Primary Care Visits Free",91278ID001,,IDN001,IDS001,IDF003,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,4,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010009-03,"Limited Cost Sharing Plan Variation",,0.702139028,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,000 ","$60 ","$1,100 ","$0 ","$900 ","$1,800 ","$0 ","$0 ",100%,"Not Applicable",No,"Silver 12 LCS with First 4 Primary Care Visits Free","$2,100 ","$200 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010009,"Silver 12 with First 4 Primary Care Visits Free",91278ID001,,IDN001,IDS001,IDF003,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,4,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010009-04,"73% AV Level Silver Plan",,0.732356796,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$75,500 ","$75500 per person | $151000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",20.00%,,,,"$15,100 ","$15100 per person | $30200 per group","Not Applicable","per person not applicable | per group not applicable","$6,500 ","$40 ","$1,000 ","$0 ","$900 ","$1,700 ","$0 ","$0 ",100%,"Not Applicable",No,"Silver 12 200 with First 4 Primary Care Visits Free","$2,100 ","$200 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010009,"Silver 12 with First 4 Primary Care Visits Free",91278ID001,,IDN001,IDS001,IDF003,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,4,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010009-05,"87% AV Level Silver Plan",,0.870538744,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,150 ","$3150 per person | $6300 per group",,,"$31,500 ","$31500 per person | $63000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$1,300 ","$1300 per person | $2600 per group",20.00%,,,,"$6,300 ","$6300 per person | $12600 per group","Not Applicable","per person not applicable | per group not applicable","$1,300 ","$20 ","$1,800 ","$0 ","$900 ","$900 ","$0 ","$0 ",100%,"Not Applicable",No,"Silver 12 150 with First 4 Primary Care Visits Free","$1,300 ","$50 ","$200 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0010009,"Silver 12 with First 4 Primary Care Visits Free",91278ID001,,IDN001,IDS001,IDF003,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"Pregnancy, Weight Loss Programs, Depression, Diabetes, Heart Disease, Asthma",,,,,4,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0010009-06,"94% AV Level Silver Plan",,0.941612131,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,150 ","$3150 per person | $6300 per group",,,"$31,500 ","$31500 per person | $63000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$100 ","$100 per person | $200 per group",10.00%,,,,"$6,300 ","$6300 per person | $12600 per group","Not Applicable","per person not applicable | per group not applicable","$100 ","$10 ","$1,200 ","$0 ","$100 ","$300 ","$80 ","$0 ",100%,"Not Applicable",No,"Silver 12 100 with First 4 Primary Care Visits Free","$100 ","$10 ","$200 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0020001,"Gold 1 with Adult Vision Services",91278ID002,,IDN001,IDS001,IDF001,Existing,HMO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"High Blood Pressure & High Cholesterol, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0020001-01,"Standard Gold On Exchange Plan",,0.783632282,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,100 ","$8100 per person | $16200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$1,550 ","$1550 per person | $3100 per group",25.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$1,900 ","$300 ","$2,400 ","$0 ","$800 ","$1,200 ","$0 ","$0 ",98%,"Not Applicable",No,"Gold 1 with Adult Vision Services","$1,700 ","$400 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0020001,"Gold 1 with Adult Vision Services",91278ID002,,IDN001,IDS001,IDF001,Existing,HMO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"High Blood Pressure & High Cholesterol, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0020001-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",98%,"Not Applicable",No,"Gold 1 Zero with Adult Vision Services","$0 ","$0 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0020001,"Gold 1 with Adult Vision Services",91278ID002,,IDN001,IDS001,IDF001,Existing,HMO,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"High Blood Pressure & High Cholesterol, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0020001-03,"Limited Cost Sharing Plan Variation",,0.783632282,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$8,100 ","$8100 per person | $16200 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$1,550 ","$1550 per person | $3100 per group",25.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$1,900 ","$300 ","$2,400 ","$0 ","$800 ","$1,200 ","$0 ","$0 ",98%,"Not Applicable",No,"Gold 1 LCS with Adult Vision Services","$1,700 ","$400 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0020002,"Silver 1 with Adult Vision Services",91278ID002,,IDN001,IDS001,IDF002,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"High Blood Pressure & High Cholesterol, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0020002-01,"Standard Silver On Exchange Plan",,0.70017959,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,850 ","$7850 per person | $15700 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,000 ","$5000 per person | $10000 per group",35.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$2,100 ","$0 ","$0 ","$800 ","$1,400 ","$0 ","$0 ",98%,"Not Applicable",No,"Silver 1 250 with Adult Vision Services","$1,200 ","$900 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0020002,"Silver 1 with Adult Vision Services",91278ID002,,IDN001,IDS001,IDF002,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"High Blood Pressure & High Cholesterol, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0020002-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",98%,"Not Applicable",No,"Silver 1 Zero with Adult Vision Services","$0 ","$0 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0020002,"Silver 1 with Adult Vision Services",91278ID002,,IDN001,IDS001,IDF002,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"High Blood Pressure & High Cholesterol, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0020002-03,"Limited Cost Sharing Plan Variation",,0.70017959,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,850 ","$7850 per person | $15700 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,000 ","$5000 per person | $10000 per group",35.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$2,100 ","$0 ","$0 ","$800 ","$1,400 ","$0 ","$0 ",98%,"Not Applicable",No,"Silver 1 LCS with Adult Vision Services","$1,200 ","$900 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0020002,"Silver 1 with Adult Vision Services",91278ID002,,IDN001,IDS001,IDF002,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"High Blood Pressure & High Cholesterol, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0020002-04,"73% AV Level Silver Plan",,0.73056813,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,775 ","$6775 per person | $13550 per group",,,"$75,500 ","$75500 per person | $151000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,500 ","$3500 per person | $7000 per group",35.00%,,,,"$15,100 ","$15100 per person | $30200 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$2,100 ","$0 ","$0 ","$800 ","$1,400 ","$0 ","$0 ",98%,"Not Applicable",No,"Silver 1 200 with Adult Vision Services","$1,200 ","$900 ","$0 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0020002,"Silver 1 with Adult Vision Services",91278ID002,,IDN001,IDS001,IDF002,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"High Blood Pressure & High Cholesterol, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0020002-05,"87% AV Level Silver Plan",,0.870156555,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$2,750 ","$2750 per person | $5500 per group",,,"$31,500 ","$31500 per person | $63000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$700 ","$700 per person | $1400 per group",25.00%,,,,"$6,300 ","$6300 per person | $12600 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$1,400 ","$0 ","$0 ","$750 ","$700 ","$10 ","$0 ",98%,"Not Applicable",No,"Silver 1 150 with Adult Vision Services","$750 ","$700 ","$100 ","$0 "
2024,ID,,91278,SERFF,1,2/12/2024,,Individual,No,,91278ID0020002,"Silver 1 with Adult Vision Services",91278ID002,,IDN001,IDS001,IDF002,Existing,HMO,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,Yes,"High Blood Pressure & High Cholesterol, Depression, Diabetes, Heart Disease, Asthma",,,,,,,1/1/2024,12/31/2024,No,,Yes,"Out-of-Network providers",No,,,,,91278ID0020002-06,"94% AV Level Silver Plan",,0.942686198,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$1,650 ","$1650 per person | $3300 per group",,,"$31,500 ","$31500 per person | $63000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",20.00%,,,,"$6,300 ","$6300 per person | $12600 per group","Not Applicable","per person not applicable | per group not applicable","$0 ","$900 ","$0 ","$0 ","$0 ","$200 ","$200 ","$0 ",98%,"Not Applicable",No,"Silver 1 100 with Adult Vision Services","$0 ","$500 ","$300 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170001,"St Luke's Health Plan Expanded Bronze",92170ID017,,IDN001,IDS001,IDF001,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170001-01,"Standard Bronze On Exchange Plan",,0.649616027,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,750 ","$7750 per person | $15500 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,750 ","$1,000 ","$400 ","$60 ","$3,900 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"St Luke's Health Plan Expanded Bronze","$2,000 ","$600 ","$0 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170001,"St Luke's Health Plan Expanded Bronze",92170ID017,,IDN001,IDS001,IDF001,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170001-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"St Luke's Health Plan Expanded Bronze","$0 ","$0 ","$0 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170001,"St Luke's Health Plan Expanded Bronze",92170ID017,,IDN001,IDS001,IDF001,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170001-03,"Limited Cost Sharing Plan Variation",,0.649616027,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,750 ","$7750 per person | $15500 per group",50.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,750 ","$1,000 ","$400 ","$60 ","$3,900 ","$500 ","$0 ","$20 ",100%,"Not Applicable",No,"St Luke's Health Plan Expanded Bronze","$2,000 ","$600 ","$0 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170002,"St Luke's Health Plan Expanded Bronze HDHP",92170ID017,,IDN001,IDS001,IDF002,Existing,POS,"Expanded Bronze",No,Both,No,No,,,Yes,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170002-01,"Standard Bronze On Exchange Plan",,0.646083379,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,200 ","$7200 per person | $14400 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,200 ","$7200 per person | $14400 per group",0.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,200 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"St Luke's Health Plan Expanded Bronze HDHP","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170002,"St Luke's Health Plan Expanded Bronze HDHP",92170ID017,,IDN001,IDS001,IDF002,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170002-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"St Luke's Health Plan Expanded Bronze HDHP","$0 ","$0 ","$0 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170002,"St Luke's Health Plan Expanded Bronze HDHP",92170ID017,,IDN001,IDS001,IDF002,Existing,POS,"Expanded Bronze",No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170002-03,"Limited Cost Sharing Plan Variation",,0.646083379,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,200 ","$7200 per person | $14400 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,200 ","$7200 per person | $14400 per group",0.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$7,200 ","$0 ","$0 ","$60 ","$5,400 ","$0 ","$0 ","$20 ",100%,"Not Applicable",No,"St Luke's Health Plan Expanded Bronze HDHP","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170003,"St Luke's Health Plan Silver",92170ID017,,IDN001,IDS001,IDF003,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170003-01,"Standard Silver On Exchange Plan",,0.715866682,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,700 ","$5700 per person | $11400 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$5,700 ","$800 ","$1,100 ","$60 ","$3,900 ","$200 ","$0 ","$20 ",100%,"Not Applicable",No,"St Luke's Health Plan Silver","$2,000 ","$400 ","$0 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170003,"St Luke's Health Plan Silver",92170ID017,,IDN001,IDS001,IDF003,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170003-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"St Luke's Health Plan Silver","$0 ","$0 ","$0 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170003,"St Luke's Health Plan Silver",92170ID017,,IDN001,IDS001,IDF003,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170003-03,"Limited Cost Sharing Plan Variation",,0.715866682,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,700 ","$5700 per person | $11400 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$5,700 ","$800 ","$1,100 ","$60 ","$3,900 ","$200 ","$0 ","$20 ",100%,"Not Applicable",No,"St Luke's Health Plan Silver","$2,000 ","$400 ","$0 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170003,"St Luke's Health Plan Silver",92170ID017,,IDN001,IDS001,IDF003,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170003-04,"73% AV Level Silver Plan",,0.739788436,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,550 ","$7550 per person | $15100 per group",,,"$47,250 ","$47250 per person | $94500 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,500 ","$5500 per person | $11000 per group",40.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$5,500 ","$800 ","$1,200 ","$60 ","$3,900 ","$200 ","$0 ","$20 ",100%,"Not Applicable",No,"St Luke's Health Plan Silver","$2,000 ","$400 ","$0 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170003,"St Luke's Health Plan Silver",92170ID017,,IDN001,IDS001,IDF003,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170003-05,"87% AV Level Silver Plan",,0.876103945,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$3,150 ","$3150 per person | $6300 per group",,,"$47,250 ","$47250 per person | $94500 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$1,000 ","$1000 per person | $2000 per group",20.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$1,000 ","$500 ","$1,500 ","$60 ","$1,000 ","$200 ","$700 ","$20 ",100%,"Not Applicable",No,"St Luke's Health Plan Silver","$1,000 ","$300 ","$100 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170003,"St Luke's Health Plan Silver",92170ID017,,IDN001,IDS001,IDF003,Existing,POS,Silver,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170003-06,"94% AV Level Silver Plan",,0.945224197,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$900 ","$900 per person | $1800 per group",,,"$47,250 ","$47250 per person | $94500 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$250 ","$250 per person | $500 per group",10.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$250 ","$400 ","$300 ","$60 ","$250 ","$100 ","$500 ","$20 ",100%,"Not Applicable",No,"St Luke's Health Plan Silver","$250 ","$200 ","$100 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170004,"St Luke's Health Plan Gold",92170ID017,,IDN001,IDS001,IDF004,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170004-01,"Standard Gold On Exchange Plan",,0.809675058,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,750 ","$7750 per person | $15500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$1,800 ","$1800 per person | $3600 per group",10.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$1,800 ","$600 ","$700 ","$60 ","$1,800 ","$200 ","$600 ","$20 ",100%,"Not Applicable",No,"St Luke's Health Plan Gold","$1,800 ","$300 ","$20 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170004,"St Luke's Health Plan Gold",92170ID017,,IDN001,IDS001,IDF004,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170004-02,"Zero Cost Sharing Plan Variation",,1,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group",,,,,,,,,,,,,,,,,,,,,"$0 ","$0 per person | $0 per group",0.00%,,,,"$0 ","$0 per person | $0 per group","$0 ","$0 per person | $0 per group","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ","$0 ",100%,"Not Applicable",No,"St Luke's Health Plan Gold","$0 ","$0 ","$0 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,Individual,No,,92170ID0170004,"St Luke's Health Plan Gold",92170ID017,,IDN001,IDS001,IDF004,Existing,POS,Gold,No,Both,No,No,,,No,,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0170004-03,"Limited Cost Sharing Plan Variation",,0.809675058,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,750 ","$7750 per person | $15500 per group",,,"$94,500 ","$94500 per person | $189000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$1,800 ","$1800 per person | $3600 per group",10.00%,,,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable","$1,800 ","$600 ","$700 ","$60 ","$1,800 ","$200 ","$600 ","$20 ",100%,"Not Applicable",No,"St Luke's Health Plan Gold","$1,800 ","$300 ","$20 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,92170ID0180001,"St Luke's Health Plan Silver 5700",92170ID018,,IDN001,IDS002,IDF002,Existing,POS,Silver,No,Both,No,No,,No,No,No,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0180001-01,"Standard Silver On Exchange Plan",,0.718869666,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$5,700 ","$5700 per person | $11400 per group",40.00%,,,,"$11,400 ","$11400 per person | $22800 per group","Not Applicable","per person not applicable | per group not applicable","$5,700 ","$700 ","$1,100 ","$60 ","$3,900 ","$200 ","$0 ","$20 ",,,No,"St Luke's Health Plan Silver 5700","$2,000 ","$300 ","$0 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,92170ID0180002,"St Luke's Health Plan Silver HDHP",92170ID018,,IDN001,IDS002,IDF003,Existing,POS,Silver,No,Both,No,No,,No,Yes,Yes,"$0.00 ","Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0180002-01,"Standard Silver On Exchange Plan",,0.703160047,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$6,500 ","$6500 per person | $13000 per group",,,"$13,000 ","$13000 per person | $26000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$4,000 ","$4000 per person | $8000 per group",40.00%,,,,"$8,000 ","$8000 per person | $16000 per group","Not Applicable","per person not applicable | per group not applicable","$4,000 ","$0 ","$2,500 ","$60 ","$4,000 ","$0 ","$500 ","$20 ",,,No,"St Luke's Health Plan Silver HDHP","$2,800 ","$0 ","$0 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,92170ID0180003,"St Luke's Health Plan Gold",92170ID018,,IDN001,IDS002,IDF004,Existing,POS,Gold,No,Both,No,No,,No,No,No,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0180003-01,"Standard Gold On Exchange Plan",,0.809675058,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$7,750 ","$7750 per person | $15500 per group",,,"$15,500 ","$15500 per person | $31000 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$1,800 ","$1800 per person | $3600 per group",10.00%,,,,"$3,600 ","$3600 per person | $7200 per group","Not Applicable","per person not applicable | per group not applicable","$1,800 ","$600 ","$700 ","$60 ","$1,800 ","$200 ","$600 ","$20 ",,,No,"St Luke's Health Plan Gold","$1,800 ","$300 ","$20 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,92170ID0180004,"St. Luke's Health Plan Bronze",92170ID018,,IDN001,IDS001,IDF004,New,POS,"Expanded Bronze",No,Both,No,No,,No,No,No,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0180004-01,"Standard Bronze On Exchange Plan",,0.649616027,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$7,000 ","$7000 per person | $14000 per group",50.00%,,,,"$14,000 ","$14000 per person | $28000 per group","Not Applicable","per person not applicable | per group not applicable","$7,000 ","$1,000 ","$700 ","$60 ","$3,900 ","$500 ","$0 ","$20 ",,,No,"St. Luke's Health Plan Bronze","$2,000 ","$600 ","$0 ","$0 "
2024,ID,,92170,SERFF,1,2/12/2024,,"SHOP (Small Group)",No,,92170ID0180005,"St. Luke's Health Plan Silver 3300",92170ID018,,IDN001,IDS002,IDF005,New,POS,Silver,No,Both,No,No,,No,No,No,,"Allows Adult and Child-Only",,No,,,,,,,,1/1/2024,12/31/2024,No,,Yes,"Medical and Pharmacy",Yes,,,,,92170ID0180005-01,"Standard Silver On Exchange Plan",,0.717908362,Yes,Yes,No,100%,,,,,,,,,,,,,,,,,,"$9,450 ","$9450 per person | $18900 per group",,,"$18,900 ","$18900 per person | $37800 per group","Not Applicable","per person not applicable | per group not applicable",,,,,,,,,,,,,,,,,,,,,"$3,300 ","$3300 per person | $6600 per group",40.00%,,,,"$6,600 ","$6600 per person | $13200 per group","Not Applicable","per person not applicable | per group not applicable","$3,300 ","$700 ","$2,100 ","$60 ","$3,300 ","$300 ","$200 ","$20 ",,,No,"St. Luke's Health Plan Silver 3300","$2,000 ","$400 ","$0 ","$0 "
