Covered Services: All plans offered on the Marketplace cover 10 Essential Health Benefits:
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- Hope Blake
- 8 years ago
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1 Introduction The NY State of Health 2015 Plan Compare provides information about health plans offered on the Individual Marketplace. Here's some general information to get you started. Metal Levels: Plans offered on the NY State of Health are available at four metal levels: Platinum, Gold, Silver and Bronze. Platinum plans have the lowest out-of-pocket cost if you use a service, but the highest premium. Bronze plans have the highest out-of- pocket cost, but the lowest premium. Covered Services: All plans offered on the Marketplace cover 10 Essential Health Benefits: Ambulatory Patient Services Emergency Services Inpatient Care Maternity and New Born Care Mental Health and Substance Use Services s Rehabilitative Care Laboratory Services Preventive, and Chronic Disease Management Pediatric Services, including vision care Standard and Non-Standard Plans: NY State of Health offers two types of plans: standard plans and non-standard plans. To make it easier to compare options, standard plans cover the same services and have the same out-of-pocket costs regardless of the insurer. The primary differences are the monthly premium charged by the insurer, the insurer s provider network and prescription drug formulary, and the plan s quality rating. Non-standard plans were designed to give you additional choices. Non-standard plans cover the same ten Essential Health Benefits as the standard plan, but they may also cover extra services like dental and/or vision care for adults. Non-standard plan may also have different out-ofpocket costs.
2 How to Use the NYSOH Plan Compare The Plan Compare is organized by county. Find the section for the county in which you reside. It will include information about all of the health plan options available to you and your family through the Marketplace. At the top of each page, you will find information that identifies the name of the insurer, the name of the plan, the plan s identification number and the metal level. The Plan Compare allows you to preview all of the plan options in your county, or select plans offered by certain insurers or at certain metal levels. Each page in the Health Plan Compare shows the standard plan and the plan you are reviewing so you can see how it compares. Pay particular attention to any difference in out-of-pocket costs and any additional services covered by the plan. The Plan Compare does not include monthly premium because the amount you will pay each month will depend on your income and family size when you apply for coverage. To see if you may qualify for financial assistance to reduce your monthly cost, visit the NY State of Health website. You can review the Plan Compare while you are on the website, or if it is more convenient you can print one or more pages and review them later. The Health Plan Compare is intended to allow you to preview the plans offered on the Individual Marketplace. Before you select and enroll in a health plan, find out which health care providers participate in the health plan s network and, if you take medication, find out if they are covered by the health plans formulary or list of covered drugs. You can find the plan s customer service numbers and provider directory links on our website at: Questions or need assistance? Visit our website at call our Customer Service Center at or meet with a NY State of Health in-person assistor in your area.
3 Queens County Individual Market Products Plan Standard Non-Standard Affinity X Emblem Health X Empire Blue Cross Blue Shield X X Fidelis X Healthfirst X X Health Republic X X Metroplus X X North Shore - LIJ Care Connect X X Oscar X X United Healthcare X Wellcare X X
4 Plan Name: Affinity Health Plan Product Name: Affinity Access Bronze ST INN Pediatric Dental Dep25 HIOS Plan ID: 57165NY Metal Level: Bronze Standard Bronze Benefits $3,000 $6,000 $6,350 $12,700 0% coinsurance
5 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Pediatric Dental Dep25 HIOS Plan ID: 57165NY Metal Level: Silver Standard Silver Benefits $5,500 $11,000 copayment $1500 copayment $150 copayment 30% coinsurance $100 copayment
6 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Pediatric Dental Dep25 HIOS Plan ID: 57165NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 $5,200 $10,400 $1,500 copayment $150 copayment 25% coinsurance $100 copayment
7 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Pediatric Dental Dep25 HIOS Plan ID: 57165NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 copayment $9 copayment $20 copayment $40 copayment $250 copayment $75 copayment 10% coinsurance $25 copayment $75 copayment
8 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Pediatric Dental Dep25 HIOS Plan ID: 57165NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $20 copayment copayment $6 copayment $100 copayment 5% coinsurance $25 copayment
9 Plan Name: Affinity Health Plan Product Name: Affinity Access Gold ST INN Pediatric Dental Dep25 HIOS Plan ID: 57165NY Metal Level: Gold Standard Gold Benefits $600 $1,200 $8,000 $25 copayment $40 copayment copayment $1,000 copayment $150 copayment $60 copayment 20% coinsurance $40 copayment $40 copayment $100 copayment
10 Plan Name: Affinity Health Plan Product Name: Affinity Access Platinum ST INN Pediatric Dental Dep25 HIOS Plan ID: 57165NY Metal Level: Platinum Standard Platinum Benefits copayment $60 copayment $500 copayment $100 copayment $60 copayment 20% coinsurance $100 copayment
11 Plan Name: Affinity Health Plan Product Name: Affinity Access Bronze ST INN Pediatric Dental Dep29 HIOS Plan ID: 57165NY Metal Level: Bronze Standard Bronze Benefits $3,000 $6,000 $6,350 $12,700 0% coinsurance
12 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Pediatric Dental Dep29 HIOS Plan ID: 57165NY Metal Level: Silver Standard Silver Benefits $5,500 $11,000 copayment $1500 copayment $150 copayment 30% coinsurance $100 copayment
13 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Pediatric Dental Dep29 HIOS Plan ID: 57165NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 $5,200 $10,400 $1,500 copayment $150 copayment 25% coinsurance $100 copayment
14 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Pediatric Dental Dep29 HIOS Plan ID: 57165NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 copayment $9 copayment $20 copayment $40 copayment $250 copayment $75 copayment 10% coinsurance $25 copayment $75 copayment
15 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Pediatric Dental Dep29 HIOS Plan ID: 57165NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $20 copayment copayment $6 copayment $100 copayment 5% coinsurance $25 copayment
16 Plan Name: Affinity Health Plan Product Name: Affinity Access Gold ST INN Pediatric Dental Dep29 HIOS Plan ID: 57165NY Metal Level: Gold Standard Gold Benefits $600 $1,200 $8,000 $25 copayment $40 copayment copayment $1,000 copayment $150 copayment $60 copayment 20% coinsurance $40 copayment $40 copayment $100 copayment
17 Plan Name: Affinity Health Plan Product Name: Affinity Access Platinum ST INN Pediatric Dental Dep29 HIOS Plan ID: 57165NY Metal Level: Platinum Standard Platinum Benefits copayment $60 copayment $500 copayment $100 copayment $60 copayment 20% coinsurance $100 copayment
18 Plan Name: Affinity Health Plan Product Name: Affinity Access Bronze ST INN Dep25 HIOS Plan ID: 57165NY Metal Level: Bronze Standard Bronze Benefits $3,000 $6,000 $6,350 $12,700 0% coinsurance
19 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Dep25 HIOS Plan ID: 57165NY Metal Level: Silver Standard Silver Benefits $5,500 $11,000 copayment $1500 copayment $150 copayment 30% coinsurance $100 copayment
20 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Dep25 HIOS Plan ID: 57165NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 $5,200 $10,400 $1,500 copayment $150 copayment 25% coinsurance $100 copayment
21 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Dep25 HIOS Plan ID: 57165NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 copayment $9 copayment $20 copayment $40 copayment $250 copayment $75 copayment 10% coinsurance $25 copayment $75 copayment
22 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Dep25 HIOS Plan ID: 57165NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $20 copayment copayment $6 copayment $100 copayment 5% coinsurance $25 copayment
23 Plan Name: Affinity Health Plan Product Name: Affinity Access Gold ST INN Dep25 HIOS Plan ID: 57165NY Metal Level: Gold Standard Gold Benefits $600 $1,200 $8,000 $25 copayment $40 copayment copayment $1,000 copayment $150 copayment $60 copayment 20% coinsurance $40 copayment $40 copayment $100 copayment
24 Plan Name: Affinity Health Plan Product Name: Affinity Access Platinum ST INN Dep25 HIOS Plan ID: 57165NY Metal Level: Platinum Standard Platinum Benefits copayment $60 copayment $500 copayment $100 copayment $60 copayment 20% coinsurance $100 copayment
25 Plan Name: Affinity Health Plan Product Name: Affinity Access Bronze ST INN Dep29 HIOS Plan ID: 57165NY Metal Level: Bronze Standard Bronze Benefits $3,000 $6,000 $6,350 $12,700 0% coinsurance
26 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Dep29 HIOS Plan ID: 57165NY Metal Level: Silver Standard Silver Benefits $5,500 $11,000 copayment $1500 copayment $150 copayment 30% coinsurance $100 copayment
27 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Dep29 HIOS Plan ID: 57165NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 $5,200 $10,400 $1,500 copayment $150 copayment 25% coinsurance $100 copayment
28 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Dep29 HIOS Plan ID: 57165NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 copayment $9 copayment $20 copayment $40 copayment $250 copayment $75 copayment 10% coinsurance $25 copayment $75 copayment
29 Plan Name: Affinity Health Plan Product Name: Affinity Access Silver ST INN Dep29 HIOS Plan ID: 57165NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $20 copayment copayment $6 copayment $100 copayment 5% coinsurance $25 copayment
30 Plan Name: Affinity Health Plan Product Name: Affinity Access Gold ST INN Dep29 HIOS Plan ID: 57165NY Metal Level: Gold Standard Gold Benefits $600 $1,200 $8,000 $25 copayment $40 copayment copayment $1,000 copayment $150 copayment $60 copayment 20% coinsurance $40 copayment $40 copayment $100 copayment
31 Plan Name: Affinity Health Plan Product Name: Affinity Access Platinum ST INN Dep29 HIOS Plan ID: 57165NY Metal Level: Platinum Standard Platinum Benefits copayment $60 copayment $500 copayment $100 copayment $60 copayment 20% coinsurance $100 copayment
32 Plan Name: Emblem Health Product Name: Select Care Bronze Bronze ST INN Dep25 HIOS Plan ID: 88582NY Metal Level: Bronze $3,000 $6,000 $6,350 $12,700 0% coinsurance Standard Bronze Benefits
33 Plan Name: Emblem Health Product Name: Select Care Silver Silver ST INN Dep25 HIOS Plan ID: 88582NY Metal Level: Silver Standard Silver Benefits $5,500 $11,000 copayment $1500 copayment $150 copayment 30% coinsurance $100 copayment
34 Plan Name: Emblem Health Product Name: Select Care Silver Silver ST INN Dep25 HIOS Plan ID: 88582NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 $5,200 $10,400 $1,500 copayment $150 copayment 25% coinsurance $100 copayment
35 Plan Name: Emblem Health Product Name: Select Care Silver Silver ST INN Dep25 HIOS Plan ID: 88582NY Metal Level: Silver Cost Share Reduction, % FPL $250 $500 Standard Silver Benefits, % FPL copayment $9 copayment $20 copayment $40 copayment $250 copayment $75 copayment 10% coinsurance $25 copayment $75 copayment
36 Plan Name: Emblem Health Product Name: Select Care Silver Silver ST INN Dep25 HIOS Plan ID: 88582NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $20 copayment copayment $6 copayment $100 copayment 5% coinsurance $25 copayment
37 Plan Name: Emblem Health Product Name: Select Care Gold Gold ST INN Dep25 HIOS Plan ID: 88582NY Metal Level: Gold $600 $1,200 $8,000 $25 copayment $40 copayment copayment Standard Gold Benefits $1,000 copayment $150 copayment $60 copayment 20% coinsurance $40 copayment $40 copayment $100 copayment
38 Plan Name: Emblem Health Product Name: Select Care Platinum Platinum ST INN Dep25 HIOS Plan ID: 88582NY Metal Level: Platinum Standard Platinum Benefits copayment $60 copayment $500 copayment $100 copayment $60 copayment 20% coinsurance $100 copayment
39 Plan Name: Emblem Health Product Name: Select Care Bronze Bronze ST INN Dep29 HIOS Plan ID: 88582NY Metal Level: Bronze $3,000 $6,000 $6,350 $12,700 0% coinsurance Standard Bronze Benefits
40 Plan Name: Emblem Health Product Name: Select Care Silver Silver ST INN Dep29 HIOS Plan ID: 88582NY Metal Level: Silver Standard Silver Benefits $5,500 $11,000 copayment $1500 copayment $150 copayment 30% coinsurance $100 copayment
41 Plan Name: Emblem Health Product Name: Select Care Silver Silver ST INN Dep29 HIOS Plan ID: 88582NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 $5,200 $10,400 $1,500 copayment $150 copayment 25% coinsurance $100 copayment
42 Plan Name: Emblem Health Product Name: Select Care Silver Silver ST INN Dep29 HIOS Plan ID: 88582NY Metal Level: Silver Cost Share Reduction, % FPL $250 $500 Standard Silver Benefits, % FPL copayment $9 copayment $20 copayment $40 copayment $250 copayment $75 copayment 10% coinsurance $25 copayment $75 copayment
43 Plan Name: Emblem Health Product Name: Select Care Silver Silver ST INN Dep29 HIOS Plan ID: 88582NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $20 copayment copayment $6 copayment $100 copayment 5% coinsurance $25 copayment
44 Plan Name: Emblem Health Product Name: Select Care Gold Gold ST INN Dep29 HIOS Plan ID: 88582NY Metal Level: Gold Standard Gold Benefits $600 $1,200 $8,000 $25 copayment $40 copayment copayment $1,000 copayment $150 copayment $60 copayment 20% coinsurance $40 copayment $40 copayment $100 copayment
45 Plan Name: Emblem Health Product Name: Select Care Silver Silver ST INN Dep29 HIOS Plan ID: 88582NY Metal Level: Platinum Standard Platinum Benefits copayment $60 copayment $500 copayment $100 copayment $60 copayment 20% coinsurance $100 copayment
46 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Bronze Standard Bronze Benefits $3,000 $6,000 $6,350 $12,700 0% coinsurance
47 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Silver Standard Silver Benefits $5,500 $11,000 copayment $1500 copayment $150 copayment 30% coinsurance $100 copayment
48 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 $5,200 $10,400 $1,500 copayment $150 copayment 25% coinsurance $100 copayment
49 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 copayment $9 copayment $20 copayment $40 copayment $250 copayment $75 copayment 10% coinsurance $25 copayment $75 copayment
50 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $20 copayment copayment $6 copayment $100 copayment 5% coinsurance $25 copayment
51 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Gold Standard Gold Benefits $600 $1,200 $8,000 $25 copayment $40 copayment copayment $1,000 copayment $150 copayment $60 copayment 20% coinsurance $40 copayment $40 copayment $100 copayment
52 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Platinum Standard Platinum Benefits copayment $60 copayment $500 copayment $100 copayment $60 copayment 20% coinsurance $100 copayment
53 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Bronze Standard Bronze Benefits $3,000 $6,000 $6,350 $12,700 0% coinsurance
54 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Silver Standard Silver Benefits $5,500 $11,000 copayment $1500 copayment $150 copayment 30% coinsurance $100 copayment
55 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 $5,200 $10,400 $1,500 copayment $150 copayment 25% coinsurance $100 copayment
56 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 copayment $9 copayment $20 copayment $40 copayment $250 copayment $75 copayment 10% coinsurance $25 copayment $75 copayment
57 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $20 copayment copayment $6 copayment $100 copayment 5% coinsurance $25 copayment
58 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Gold Standard Gold Benefits $600 $1,200 $8,000 $25 copayment $40 copayment copayment $1,000 copayment $150 copayment $60 copayment 20% coinsurance $40 copayment $40 copayment $100 copayment
59 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Platinum Standard Platinum Benefits copayment $60 copayment $500 copayment $100 copayment $60 copayment 20% coinsurance $100 copayment
60 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Bronze Standard Bronze Benefits How Does this Non-Standard Product Compare? $3,000 $6,000 $6,000 $12,000 $6,350 $12,700 $6,600 $13,200 $45 copayment 20% coinsurance 0% coinsurance 0% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance $600 copayment $500 copayment 20% coinsurance Covered Therapies 20% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 20% coinsurance Services Diagnostic & Routine 20% coinsurance Imaging 20% coinsurance 20% coinsurance 20% coinsurance :
61 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Bronze Standard Bronze Benefits How Does this Non-Standard Product Compare? $3,000 $6,000 $5,600 $11,200 $6,350 $12,700 $6,600 $13,200 40% coinsurance 0% coinsurance 0% coinsurance 40% coinsurance 40% coinsurance 40% coinsurance $1000 copayment $500 copayment 40% coinsurance Covered Therapies 40% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 40% coinsurance Services Diagnostic & Routine 40% coinsurance Imaging 40% coinsurance 40% coinsurance 40% coinsurance 25% coinsurance 0% coinsurance :
62 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Silver Standard Silver Benefits How Does this Non-Standard Product Compare? $2,250 $4,500 $5,500 $11,000 $5,800 $11,600 25% coinsurance copayment copayment 25% coinsurance 25% coinsurance 25% coinsurance $1500 copayment $1,000 copayment $150 copayment $200 copayment 30% coinsurance 25% coinsurance Covered Therapies 25% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 25% coinsurance Services Diagnostic & Routine 25% coinsurance Imaging $100 copayment 25% coinsurance 25% coinsurance 25% coinsurance 25% coinsurance :
63 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 How Does this Non-Standard Product Compare? $1,750 $3,500 $5,200 $10,400 $5,200 $10,400 20% coinsurance copayment copayment 20% coinsurance 20% coinsurance 20% coinsurance $1,500 copayment $1,000 copayment $150 copayment $200 copayment 25% coinsurance 20% coinsurance Covered Therapies 20% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 20% coinsurance Services Diagnostic & Routine 20% coinsurance Imaging $100 copayment 20% coinsurance 20% coinsurance 20% coinsurance 25% coinsurance copayment :
64 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 How Does this Non-Standard Product Compare? $250 $500 $8,000 15% coinsurance copayment copayment $9 copayment $20 copayment $40 copayment 15% coinsurance 15% coinsurance 15% coinsurance $250 copayment $250 copayment $75 copayment $100 copayment 10% coinsurance 15% coinsurance Covered Therapies $25 copayment 15% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 15% coinsurance Services Diagnostic & Routine 15% coinsurance Imaging $75 copayment 15% coinsurance 15% coinsurance 15% coinsurance 25% coinsurance copayment :
65 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL How Does this Non-Standard Product Compare? $1,000 $1,600 $3,200 $5 copayment $20 copayment 10% coinsurance copayment copayment $6 copayment 10% coinsurance 10% coinsurance 10% coinsurance $100 copayment $100 copayment $25 copayment 5% coinsurance 10% coinsurance Covered Therapies 10% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 10% coinsurance Services Diagnostic & Routine 10% coinsurance Imaging $25 copayment 10% coinsurance 10% coinsurance 10% coinsurance 25% coinsurance copayment :
66 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Bronze Standard Bronze Benefits How Does this Non-Standard Product Compare? $3,000 $6,000 $6,000 $12,000 $6,350 $12,700 $6,600 $13,200 $45 copayment 20% coinsurance 0% coinsurance 0% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance $600 copayment $500 copayment 20% coinsurance Covered Therapies 20% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 20% coinsurance Services Diagnostic & Routine 20% coinsurance Imaging 20% coinsurance 20% coinsurance 20% coinsurance :
67 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Bronze Standard Bronze Benefits How Does this Non-Standard Product Compare? $3,000 $6,000 $5,600 $11,200 $6,350 $12,700 $6,600 $13,200 40% coinsurance 0% coinsurance 0% coinsurance 40% coinsurance 40% coinsurance 40% coinsurance $1000 copayment $500 copayment 40% coinsurance Covered Therapies 40% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 40% coinsurance Services Diagnostic & Routine 40% coinsurance Imaging 40% coinsurance 40% coinsurance 40% coinsurance 25% coinsurance 0% coinsurance :
68 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Silver Standard Silver Benefits How Does this Non-Standard Product Compare? $2,250 $4,500 $5,500 $11,000 $5,800 $11,600 25% coinsurance copayment copayment 25% coinsurance 25% coinsurance 25% coinsurance $1500 copayment $1,000 copayment $150 copayment $200 copayment 30% coinsurance 25% coinsurance Covered Therapies 25% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 25% coinsurance Services Diagnostic & Routine 25% coinsurance Imaging $100 copayment 25% coinsurance 25% coinsurance 25% coinsurance 25% coinsurance :
69 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 How Does this Non-Standard Product Compare? $1,750 $3,500 $5,200 $10,400 $5,200 $10,400 20% coinsurance copayment copayment 20% coinsurance 20% coinsurance 20% coinsurance $1,500 copayment $1,000 copayment $150 copayment $200 copayment 25% coinsurance 20% coinsurance Covered Therapies 20% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 20% coinsurance Services Diagnostic & Routine 20% coinsurance Imaging $100 copayment 20% coinsurance 20% coinsurance 20% coinsurance 25% coinsurance copayment :
70 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 How Does this Non-Standard Product Compare? $250 $500 $8,000 15% coinsurance copayment copayment $9 copayment $20 copayment $40 copayment 15% coinsurance 15% coinsurance 15% coinsurance $250 copayment $250 copayment $75 copayment $100 copayment 10% coinsurance 15% coinsurance Covered Therapies $25 copayment 15% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 15% coinsurance Services Diagnostic & Routine 15% coinsurance Imaging $75 copayment 15% coinsurance 15% coinsurance 15% coinsurance 25% coinsurance copayment :
71 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL How Does this Non-Standard Product Compare? $1,000 $1,600 $3,200 $5 copayment $20 copayment 10% coinsurance copayment copayment $6 copayment 10% coinsurance 10% coinsurance 10% coinsurance $100 copayment $100 copayment $25 copayment 5% coinsurance 10% coinsurance Covered Therapies 10% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 10% coinsurance Services Diagnostic & Routine 10% coinsurance Imaging $25 copayment 10% coinsurance 10% coinsurance 10% coinsurance 25% coinsurance copayment :
72 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Silver Standard Silver Benefits How Does this Non-Standard Product Compare? $2,450 $4,900 $5,500 $11,000 $6,450 $12,900 10% coinsurance 10% coinsurance copayment copayment Additional Non-Standard Benefits: Health Savings Account Eligible 10% coinsurance 10% coinsurance 10% coinsurance $1500 copayment $1,000 copayment $150 copayment $200 copayment 30% coinsurance 10% coinsurance Covered Therapies 10% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 10% coinsurance Services Diagnostic & Routine 10% coinsurance Imaging $100 copayment 10% coinsurance 10% coinsurance 10% coinsurance 0% coinsurance copayment :
73 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 Additional Non-Standard Benefits: Health Savings Account Eligible How Does this Non-Standard Product Compare? $2,250 $4,500 $5,200 $10,400 $3,750 $7,500 10% coinsurance 10% coinsurance copayment copayment 10% coinsurance 10% coinsurance 10% coinsurance $1,500 copayment 10% coinsurance $150 copayment $200 copayment 25% coinsurance 10% coinsurance Covered Therapies 10% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 10% coinsurance Services Diagnostic & Routine 10% coinsurance Imaging $100 copayment 10% coinsurance 10% coinsurance 10% coinsurance 0% coinsurance copayment :
74 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 Additional Non-Standard Benefits: Health Savings Account Eligible How Does this Non-Standard Product Compare? $1,100 $2,200 $1,100 $2,200 copayment copayment copayment copayment $9 copayment $20 copayment $40 copayment copayment copayment copayment $250 copayment copayment $75 copayment copayment copayment 10% coinsurance 0% coinsurance Covered Therapies $25 copayment copayment (PT/OT/ST) Diagnostic & Routine Lab copayment Services Diagnostic & Routine copayment Imaging $75 copayment copayment copayment copayment copayment copayment :
75 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL Additional Non-Standard Benefits: Health Savings Account Eligible How Does this Non-Standard Product Compare? $475 $950 $1,000 $475 $950 copayment $20 copayment copayment copayment copayment $6 copayment copayment copayment copayment $100 copayment copayment copayment copayment 5% coinsurance 0% coinsurance Covered Therapies copayment (PT/OT/ST) Diagnostic & Routine Lab copayment Services Diagnostic & Routine copayment Imaging $25 copayment copayment copayment copayment copayment copayment :
76 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Silver Standard Silver Benefits How Does this Non-Standard Product Compare? $2,450 $4,900 $5,500 $11,000 $6,450 $12,900 10% coinsurance 10% coinsurance copayment copayment Additional Non-Standard Benefits: Health Savings Account Eligible 10% coinsurance 10% coinsurance 10% coinsurance $1500 copayment $1,000 copayment $150 copayment $200 copayment 30% coinsurance 10% coinsurance Covered Therapies 10% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 10% coinsurance Services Diagnostic & Routine 10% coinsurance Imaging $100 copayment 10% coinsurance 10% coinsurance 10% coinsurance 0% coinsurance copayment :
77 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 Additional Non-Standard Benefits: Health Savings Account Eligible How Does this Non-Standard Product Compare? $2,250 $4,500 $5,200 $10,400 $3,750 $7,500 10% coinsurance 10% coinsurance copayment copayment 10% coinsurance 10% coinsurance 10% coinsurance $1,500 copayment 10% coinsurance $150 copayment $200 copayment 25% coinsurance 10% coinsurance Covered Therapies 10% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 10% coinsurance Services Diagnostic & Routine 10% coinsurance Imaging $100 copayment 10% coinsurance 10% coinsurance 10% coinsurance 0% coinsurance copayment :
78 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 Additional Non-Standard Benefits: Health Savings Account Eligible How Does this Non-Standard Product Compare? $1,100 $2,200 $1,100 $2,200 copayment copayment copayment copayment $9 copayment $20 copayment $40 copayment copayment copayment copayment $250 copayment copayment $75 copayment copayment copayment 10% coinsurance 0% coinsurance Covered Therapies $25 copayment copayment (PT/OT/ST) Diagnostic & Routine Lab copayment Services Diagnostic & Routine copayment Imaging $75 copayment copayment copayment copayment copayment copayment :
79 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL Additional Non-Standard Benefits: Health Savings Account Eligible How Does this Non-Standard Product Compare? $475 $950 $1,000 $475 $950 copayment $20 copayment copayment copayment copayment $6 copayment copayment copayment copayment $100 copayment copayment copayment copayment 5% coinsurance 0% coinsurance Covered Therapies copayment (PT/OT/ST) Diagnostic & Routine Lab copayment Services Diagnostic & Routine copayment Imaging $25 copayment copayment copayment copayment copayment copayment :
80 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Gold Standard Gold Benefits How Does this Non-Standard Product Compare? $600 $1,200 $1,000 $8,000 $6,550 $13,100 $25 copayment $40 copayment 10% coinsurance copayment copayment $40 copayment 10% coinsurance $1,000 copayment $1000 copayment $150 copayment $200 copayment $60 copayment 20% coinsurance 10% coinsurance Covered Therapies 10% coinsurance (PT/OT/ST) Diagnostic & Routine Lab $40 copayment 10% coinsurance Services Diagnostic & Routine $40 copayment 10% coinsurance Imaging $100 copayment 10% coinsurance 10% coinsurance 10% coinsurance 25% coinsurance copayment :
81 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Gold Standard Gold Benefits How Does this Non-Standard Product Compare? $600 $1,200 $1,000 $8,000 $6,550 $13,100 $25 copayment $40 copayment 10% coinsurance copayment copayment $40 copayment 10% coinsurance $1,000 copayment $1000 copayment $150 copayment $200 copayment $60 copayment 20% coinsurance 10% coinsurance Covered Therapies 10% coinsurance (PT/OT/ST) Diagnostic & Routine Lab $40 copayment 10% coinsurance Services Diagnostic & Routine $40 copayment 10% coinsurance Imaging $100 copayment 10% coinsurance 10% coinsurance 10% coinsurance 25% coinsurance copayment :
82 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 25 HIOS Plan ID: 80519NY Metal Level: Platinum Standard Platinum Benefits How Does this Non-Standard Product Compare? $200 $400 $3,500 $7,000 $20 copayment copayment copayment $60 copayment $500 copayment $300 copayment $100 copayment $150 copayment $60 copayment 20% coinsurance 5% coinsurance Covered Therapies 5% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 5% coinsurance Services Diagnostic & Routine 5% coinsurance Imaging $100 copayment 5% coinsurance 5% coinsurance 5% coinsurance copayment copayment :
83 Plan Name: Empire Blue Cross Blue Shield Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 29 HIOS Plan ID: 80519NY Metal Level: Platinum Standard Platinum Benefits How Does this Non-Standard Product Compare? $200 $400 $3,500 $7,000 $20 copayment copayment copayment $60 copayment $500 copayment $300 copayment $100 copayment $150 copayment $60 copayment 20% coinsurance 5% coinsurance Covered Therapies 5% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 5% coinsurance Services Diagnostic & Routine 5% coinsurance Imaging $100 copayment 5% coinsurance 5% coinsurance 5% coinsurance copayment copayment :
84 Plan Name: Empire Blue Cross Blue Shield Multi-State Plan Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep 25, a Multi-State Plan HIOS Plan ID: 80519NY Metal Level: Silver Standard Silver Benefits How Does this Non-Standard Product Compare? $2,450 $4,900 $5,500 $11,000 $6,450 $12,900 10% coinsurance 10% coinsurance copayment 0$ copayment Additional Non-Standard Benefits: Health Savings Account Eligible 10% coinsurance 10% coinsurance 10% coinsurance $1,500 copayment $1,000 copayment $150 copayment $200 copayment 30% coinsurance 10% copayment Covered Therapies 10% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 10% coinsurance Services Diagnostic & Routine 10% coinsurance Imaging $100 copayment 10% coinsurance 10% coinsurance 10% coinsurance 25% coinsurance copayment :
85 Plan Name: Empire Blue Cross Blue Shield Multi-State Plan Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep 25, a Multi-State Plan HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 Additional Non-Standard Benefits: Health Savings Account Eligible How Does this Non-Standard Product Compare? $2,250 $4,500 $5,200 $10,400 $3,750 $7,500 10% coinsurance 10% coinsurance 0$ copayment 10% coinsurance 10% coinsurance 10% coinsurance $1,500 copayment 10% coinsurance $150 copayment $200 copayment 25% coinsurance 10% copayment Covered Therapies 10% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 10% coinsurance Services Diagnostic & Routine 10% coinsurance Imaging $100 copayment 10% coinsurance 10% coinsurance 10% coinsurance 25% coinsurance copayment :
86 Plan Name: Empire Blue Cross Blue Shield Multi-State Plan Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep 25, a Multi-State Plan HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 Additional Non-Standard Benefits: Health Savings Account Eligible How Does this Non-Standard Product Compare? $1,100 $2,200 $1,100 $2,200 0% coinsurance 0% coinsurance copayment 0% copayment $9 copayment $20 copayment $40 copayment 0% coinsurance 0% coinsurance 0% coinsurance $250 copayment 0% coinsurance $75 copayment 0% coinsurance 0% coinsurance 10% coinsurance 0% coinsurance Covered Therapies $25 copayment 0% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 0% coinsurance Services Diagnostic & Routine 0% coinsurance Imaging $75 copayment 0% coinsurance 0% coinsurance 0% coinsurance 25% coinsurance 0% coinsurance :
87 Plan Name: Empire Blue Cross Blue Shield Multi-State Plan Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep 25, a Multi-State Plan HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL Additional Non-Standard Benefits: Health Savings Account Eligible How Does this Non-Standard Product Compare? $475 $950 $1,000 $475 $950 0% coinsurance $20 copayment 0% coinsurance copayment 0% copayment $6 copayment 0% coinsurance 0% coinsurance 0% coinsurance $100 copayment 0% coinsurance 0% coinsurance 0% coinsurance 5% coinsurance 0% coinsurance Covered Therapies 0% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 0% coinsurance Services Diagnostic & Routine 0% coinsurance Imaging $25 copayment 0% coinsurance 0% coinsurance 0% coinsurance 25% coinsurance 0% coinsurance :
88 Plan Name: Empire Blue Cross Blue Shield Multi-State Plan Product Name: Empire Blue Cross Blue Shield HMO 1000 Gold NS INN Pediatric Dental Dep 25, a Multi-State Plan HIOS Plan ID: 80519NY Metal Level: Gold Standard Gold Benefits How Does this Non-Standard Product Compare? $600 $1,200 $1,000 $8,000 $6.550 $13,100 $25 copayment $40 copayment 10% coinsurance copayment copayment $40 copayment 10% coinsurance $1,000 copayment $1,000 copayment $150 copayment $200 copayment $60 copayment 20% coinsurance 10% coinsurance Covered Therapies 10% coinsurance (PT/OT/ST) Diagnostic & Routine Lab $40 copayment 10% coinsurance Services Diagnostic & Routine $40 copayment 10% coinsurance Imaging $100 copayment 10% coinsurance 10% coinsurance 10% coinsurance 25% coinsurance copayment :
89 Plan Name: Empire Blue Cross Blue Shield Multi-State Plan Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep 29, a Multi-State Plan HIOS Plan ID: 80519NY Metal Level: Silver Standard Silver Benefits How Does this Non-Standard Product Compare? $2,450 $4,900 $5,500 $11,000 $6,450 $12,900 10% coinsurance 10% coinsurance copayment 0$ copayment Additional Non-Standard Benefits: Health Savings Account Eligible 10% coinsurance 10% coinsurance 10% coinsurance $1,500 copayment $1,000 copayment $150 copayment $200 copayment 30% coinsurance 10% copayment Covered Therapies 10% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 10% coinsurance Services Diagnostic & Routine 10% coinsurance Imaging $100 copayment 10% coinsurance 10% coinsurance 10% coinsurance 25% coinsurance copayment :
90 Plan Name: Empire Blue Cross Blue Shield Multi-State Plan Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep 29, a Multi-State Plan HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 Additional Non-Standard Benefits: Health Savings Account Eligible How Does this Non-Standard Product Compare? $2,250 $4,500 $5,200 $10,400 $3,750 $7,500 10% coinsurance 10% coinsurance 0$ copayment 10% coinsurance 10% coinsurance 10% coinsurance $1,500 copayment 10% coinsurance $150 copayment $200 copayment 25% coinsurance 10% copayment Covered Therapies 10% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 10% coinsurance Services Diagnostic & Routine 10% coinsurance Imaging $100 copayment 10% coinsurance 10% coinsurance 10% coinsurance 25% coinsurance copayment :
91 Plan Name: Empire Blue Cross Blue Shield Multi-State Plan Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep 29, a Multi-State Plan HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 Additional Non-Standard Benefits: Health Savings Account Eligible How Does this Non-Standard Product Compare? $1,100 $2,200 $1,100 $2,200 0% coinsurance 0% coinsurance copayment 0% copayment $9 copayment $20 copayment $40 copayment 0% coinsurance 0% coinsurance 0% coinsurance $250 copayment 0% coinsurance $75 copayment 0% coinsurance 0% coinsurance 10% coinsurance 0% coinsurance Covered Therapies $25 copayment 0% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 0% coinsurance Services Diagnostic & Routine 0% coinsurance Imaging $75 copayment 0% coinsurance 0% coinsurance 0% coinsurance 25% coinsurance 0% coinsurance :
92 Plan Name: Empire Blue Cross Blue Shield Multi-State Plan Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep 29, a Multi-State Plan HIOS Plan ID: 80519NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL Additional Non-Standard Benefits: Health Savings Account Eligible How Does this Non-Standard Product Compare? $475 $950 $1,000 $475 $950 0% coinsurance $20 copayment 0% coinsurance copayment 0% copayment $6 copayment 0% coinsurance 0% coinsurance 0% coinsurance $100 copayment 0% coinsurance 0% coinsurance 0% coinsurance 5% coinsurance 0% coinsurance Covered Therapies 0% coinsurance (PT/OT/ST) Diagnostic & Routine Lab 0% coinsurance Services Diagnostic & Routine 0% coinsurance Imaging $25 copayment 0% coinsurance 0% coinsurance 0% coinsurance 25% coinsurance 0% coinsurance :
93 Plan Name: Empire Blue Cross Blue Shield Multi-State Plan Product Name: Empire Blue Cross Blue Shield HMO 1000 Gold NS INN Pediatric Dental Dep 29, a Multi-State Plan HIOS Plan ID: 80519NY Metal Level: Gold Standard Gold Benefits How Does this Non-Standard Product Compare? $600 $1,200 $1,000 $8,000 $6.550 $13,100 $25 copayment $40 copayment 10% coinsurance copayment copayment $40 copayment 10% coinsurance $1,000 copayment $1,000 copayment $150 copayment $200 copayment $60 copayment 20% coinsurance 10% coinsurance Covered Therapies 10% coinsurance (PT/OT/ST) Diagnostic & Routine Lab $40 copayment 10% coinsurance Services Diagnostic & Routine $40 copayment 10% coinsurance Imaging $100 copayment 10% coinsurance 10% coinsurance 10% coinsurance 25% coinsurance copayment :
94 Plan Name: Fidelis Care Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY Metal Level: Bronze Standard Bronze Benefits $3,000 $6,000 $6,350 $12,700 0% coinsurance
95 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY Metal Level: Silver Standard Silver Benefits $5,500 $11,000 copayment $1500 copayment $150 copayment 30% coinsurance $100 copayment
96 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 $5,200 $10,400 $1,500 copayment $150 copayment 25% coinsurance $100 copayment
97 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 copayment $9 copayment $20 copayment $40 copayment $250 copayment $75 copayment 10% coinsurance $25 copayment $75 copayment
98 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $20 copayment copayment $6 copayment $100 copayment 5% coinsurance $25 copayment
99 Plan Name: Fidelis Care Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY Metal Level: Gold Standard Gold Benefits $600 $1,200 $8,000 $25 copayment $40 copayment copayment $1,000 copayment $150 copayment $60 copayment 20% coinsurance $40 copayment $40 copayment $100 copayment
100 Plan Name: Fidelis Care Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY Metal Level: Platinum Standard Platinum Benefits copayment $60 copayment $500 copayment $100 copayment $60 copayment 20% coinsurance $100 copayment
101 Plan Name: Fidelis Care Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY Metal Level: Bronze Standard Bronze Benefits $3,000 $6,000 $6,350 $12,700 0% coinsurance
102 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY Metal Level: Silver Standard Silver Benefits $5,500 $11,000 copayment $1500 copayment $150 copayment 30% coinsurance $100 copayment
103 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 $5,200 $10,400 $1,500 copayment $150 copayment 25% coinsurance $100 copayment
104 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 copayment $9 copayment $20 copayment $40 copayment $250 copayment $75 copayment 10% coinsurance $25 copayment $75 copayment
105 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $20 copayment copayment $6 copayment $100 copayment 5% coinsurance $25 copayment
106 Plan Name: Fidelis Care Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY Metal Level: Gold Standard Gold Benefits $600 $1,200 $8,000 $25 copayment $40 copayment copayment $1,000 copayment $150 copayment $60 copayment 20% coinsurance $40 copayment $40 copayment $100 copayment
107 Plan Name: Fidelis Care Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY Metal Level: Platinum Standard Platinum Benefits copayment $60 copayment $500 copayment $100 copayment $60 copayment 20% coinsurance $100 copayment
108 Plan Name: Health Republic Insurance Product Name: EssentialCare Bronze ST INN Dep25 HIOS Plan ID: 71644NY Metal Level: Bronze Standard Bronze Benefits $3,000 $6,000 $6,350 $12,700 0% coinsurance
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