HEALTHFIRST PHSP, INC. Rate Manual Pursuant to New York ......Rate Manual Pursuant to New York...
Transcript of HEALTHFIRST PHSP, INC. Rate Manual Pursuant to New York ......Rate Manual Pursuant to New York...
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HEALTHFIRST PHSP, INC.
Rate Manual Pursuant to New York Insurance Law Section 4308(c)
Individual HMO Rates and Forms Submission
Effective January 1, 2021
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TABLE OF CONTENTS
I. On-Exchange Individual Plan Rates………………………………………………………………………………… 3 A. New York City rating region (#4) rates…………………………………………………….……….……... 4
B. Long Island rating region (#8) rates………………….…………………………….……….……………... 7
II. Off-Exchange Individual Plan Rates………………………………………………………………………………… 10 A. New York City rating region (#4) rates…..……………………………………….………………………... 11
B. Long Island rating region (#8) rates………………….…………………………….………...……………....14
III. Rating Factors, Rate Calculations, Loss Ratios, and Commissions/Fees………………………….17
IV. Description of Benefits, Types of Coverage, Limitations, & Exclusions…………………………..22
A. Healthfirst Standard Benefit Descriptions (On & Off Exchange)………………….…..………... 23
B. Healthfirst Non-Standard Plans Benefit Descriptions (On & Off Exchange)...…………….. 26
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SECTION I
On-Exchange Individual HMO Plan Rates
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Section I.A – Rate Pages: On-Exchange Standard & Non-Standard Plans –Rating Region #4
HEALTHFIRST PHSP, INC. ON-EXCHANGE INDIVIDUAL HMO STANDARD & NON-STANDARD PLANS
RATE PAGES - EFFECTIVE JANUARY 1, 2021 AREA: New York City Rating Region (NEW YORK, KINGS, QUEENS, RICHMOND, BRONX, WESTCHESTER, & ROCKLAND COUNTIES) –
Rating Region #4
Platinum
Applicable Form Numbers: HF-STDIND-21, HF-STDCO-21, HF-PSOB-21, HF-NoCSSOB-21
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst Platinum Leaf 91237NY0020015 Standard, Age 26 $929.26 $1,858.52 $1,579.74 $2,648.39
Healthfirst Platinum Leaf, Age 29 Rider 91237NY0020016 Standard, Age 29 $938.55 $1,877.10 $1,595.54 $2,674.87
Healthfirst Platinum Leaf Premier 91237NY0020058 Non-Standard, Age 26 $961.61 $1,923.22 $1,634.74 $2,740.59
Healthfirst Platinum Leaf Premier, Age 29 Rider 91237NY0020059 Non-Standard, Age 29 $971.22 $1,942.44 $1,651.07 $2,767.98
One Child
Two Children
Three or More
Healthfirst Platinum Leaf Child-Only 91237NY0020026 Child-Only $382.86 $765.72 $1,148.58
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Gold
Applicable Form Numbers: HF-STDIND-21, HF-GSOB-21, HF-GSOBNS-21, HF-NoCSSOB-21
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst Gold Leaf 91237NY0020011 Standard, Age 26 $738.27 $1,476.54 $1,255.06 $2,104.07
Healthfirst Gold Leaf, Age 29 Rider 91237NY0020012 Standard, Age 29 $745.63 $1,491.26 $1,267.57 $2,125.05
Healthfirst Gold Leaf Premier 91237NY0020056 Non-Standard, Age 26 $771.23 $1,542.46 $1,311.09 $2,198.01
Healthfirst Gold Leaf Premier, Age 29 Rider 91237NY0020057 Non-Standard, Age 29 $778.94 $1,557.88 $1,324.20 $2,219.98
One Child Two Children
Three or More
Healthfirst Gold Leaf Child-Only 91237NY0020024 Child-Only $304.17 $608.34 $912.51
Silver
Applicable Form Numbers: HF-STDIND-21, HF-STDCO-21, HF-SSOB-21, HF-SSOBNS-21, HF-S200SOB-21, HF-S200SOBNS-21, HF-S150SOB-21,
HF-S100SOB-21, HF-NoCSSOB-21
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst Silver Leaf 91237NY0020007 Standard, Age 26 $611.17 $1,222.34 $1,038.99 $1,741.83
Healthfirst Silver Leaf, Age 29 Rider 91237NY0020008 Standard, Age 29 $617.29 $1,234.58 $1,049.39 $1,759.28
Healthfirst Silver Leaf Premier 91237NY0020054 Non-Standard, Age 26 $636.70 $1,273.40 $1,082.39 $1,814.60
Healthfirst Silver Leaf Premier, Age 29 Rider 91237NY0020055 Non-Standard, Age 29 $643.08 $1,286.16 $1,093.24 $1,832.78
One Child
Two Children Three or
More
Healthfirst Silver Leaf Child-Only 91237NY0020022 Child-Only $251.81 $503.62 $755.43
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Bronze
Applicable Form Numbers: HF-STDIND-21, HF-STDCO-21, HF-BSOB-21, HF-NoCSSOB-21
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst Bronze Leaf 91237NY0020003 Standard, Age 26 $457.26 $914.52 $777.34 $1,303.19
Healthfirst Bronze Leaf, Age 29 Rider 91237NY0020004 Standard, Age 29 $461.81 $923.62 $785.08 $1,316.16
Healthfirst Bronze Leaf Premier 91237NY0020052 Non-Standard, Age 26 $473.15 $946.30 $804.36 $1,348.48
Healthfirst Bronze Leaf Premier, Age 29 Rider 91237NY0020053 Non-Standard, Age 29 $477.90 $955.80 $812.43 $1,362.02
One Child
Two Children
Three or More
Healthfirst Bronze Leaf Child-Only 91237NY0020020 Child-Only $188.38 $376.76 $565.14
Catastrophic
Applicable Form Numbers: HF-STDCC-21, HF-CCSOB-21, HF-NoCSSOB-21
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst Green Leaf 91237NY0020018 Standard, Age 26 $282.07 $564.14 $479.52 $803.90
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Section I.B – Rate Pages: On-Exchange Standard & Non-Standard Plans –Rating Region #8
HEALTHFIRST PHSP, INC. ON-EXCHANGE INDIVIDUAL HMO STANDARD & NON-STANDARD PLANS
RATE PAGES - EFFECTIVE JANUARY 1, 2021 AREA: Long Island Rating Region (NASSAU & SUFFOLK COUNTIES) – Rating Region #8
Platinum
Applicable Form Numbers: HF-STDIND-21, HF-STDCO-21, HF-PSOB-21, HF-NoCSSOB-21
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst Platinum Leaf 91237NY0020015 Standard, Age 26 $929.26 $1,858.52 $1,579.74 $2,648.39
Healthfirst Platinum Leaf, Age 29 Rider 91237NY0020016 Standard, Age 29 $938.55 $1,877.10 $1,595.54 $2,674.87
Healthfirst Platinum Leaf Premier 91237NY0020058 Non-Standard, Age 26 $961.61 $1,923.22 $1,634.74 $2,740.59
Healthfirst Platinum Leaf Premier, Age 29 Rider 91237NY0020059 Non-Standard, Age 29 $971.22 $1,942.44 $1,651.07 $2,767.98
One Child
Two Children
Three or More
Healthfirst Platinum Leaf Child-Only 91237NY0020026 Child-Only $382.86 $765.72 $1,148.58
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Gold
Applicable Form Numbers: HF-STDIND-21, HF-GSOB-21, HF-GSOBNS-21, HF-NoCSSOB-21
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst Gold Leaf 91237NY0020011 Standard, Age 26 $738.27 $1,476.54 $1,255.06 $2,104.07
Healthfirst Gold Leaf, Age 29 Rider 91237NY0020012 Standard, Age 29 $745.63 $1,491.26 $1,267.57 $2,125.05
Healthfirst Gold Leaf Premier 91237NY0020056 Non-Standard, Age 26 $771.23 $1,542.46 $1,311.09 $2,198.01
Healthfirst Gold Leaf Premier, Age 29 Rider 91237NY0020057 Non-Standard, Age 29 $778.94 $1,557.88 $1,324.20 $2,219.98
One Child
Two Children
Three or More
Healthfirst Gold Leaf Child-Only 91237NY0020024 Child-Only $304.17 $608.34 $912.51
Silver
Applicable Form Numbers: HF-STDIND-21, HF-STDCO-21, HF-SSOB-21, HF-SSOBNS-21, HF-S200SOB-21, HF-S200SOBNS-21, HF-S150SOB-21,
HF-S100SOB-21, HF-NoCSSOB-21
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst Silver Leaf 91237NY0020007 Standard, Age 26 $611.17 $1,222.34 $1,038.99 $1,741.83
Healthfirst Silver Leaf, Age 29 Rider 91237NY0020008 Standard, Age 29 $617.29 $1,234.58 $1,049.39 $1,759.28
Healthfirst Silver Leaf Premier 91237NY0020054 Non-Standard, Age 26 $636.70 $1,273.40 $1,082.39 $1,814.60
Healthfirst Silver Leaf Premier, Age 29 Rider 91237NY0020055 Non-Standard, Age 29 $643.08 $1,286.16 $1,093.24 $1,832.78
One Child
Two Children Three or More
Healthfirst Silver Leaf Child-Only 91237NY0020022 Child-Only $251.81 $503.62 $755.43
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Bronze
Applicable Form Numbers: HF-STDIND-21, HF-STDCO-21, HF-BSOB-21, HF-NoCSSOB-21
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst Bronze Leaf 91237NY0020003 Standard, Age 26 $457.26 $914.52 $777.34 $1,303.19
Healthfirst Bronze Leaf, Age 29 Rider 91237NY0020004 Standard, Age 29 $461.81 $923.62 $785.08 $1,316.16
Healthfirst Bronze Leaf Premier 91237NY0020052 Non-Standard, Age 26 $473.15 $946.30 $804.36 $1,348.48
Healthfirst Bronze Leaf Premier, Age 29 Rider 91237NY0020053 Non-Standard, Age 29 $477.90 $955.80 $812.43 $1,362.02
One Child
Two Children
Three or More
Healthfirst Bronze Leaf Child-Only 91237NY0020020 Child-Only $188.38 $376.76 $565.14
Catastrophic
Applicable Form Numbers: HF-STDCC-21, HF-CCSOB-21, HF-NoCSSOB-21
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst Green Leaf 91237NY0020018 Standard, Age 26 $282.07 $564.14 $479.52 $803.90
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SECTION II
Off-Exchange Individual HMO Plan Rates
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Section II.A – Rate Pages: Off-Exchange Standard Plans –Rating Region #4
HEALTHFIRST PHSP, INC. OFF-EXCHANGE INDIVIDUAL HMO STANDARD & NON-STANDARD PLANS
RATE PAGES - EFFECTIVE JANUARY 1, 2021 AREA: New York City Rating Region (NEW YORK, KINGS, QUEENS, RICHMOND, BRONX, WESTCHESTER, & ROCKLAND COUNTIES) –
Rating Region #4
Platinum
Applicable Form Numbers: HF-STDIND-21-OFF, HF-PSOB-21-OFF
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst HMO A 91237NY0020039 Standard, Age 26 $929.26 $1,858.52 $1,579.74 $2,648.39
Healthfirst HMO A, Age 29 Rider 91237NY0020040 Standard, Age 29 $938.55 $1,877.10 $1,595.54 $2,674.87
Healthfirst HMO A-VAD 91237NY0020067 Non-Standard, Age 26 $961.61 $1,923.22 $1,634.74 $2,740.59
Healthfirst HMO A-VAD, Age 29 Rider 91237NY0020068 Non-Standard, Age 29 $971.22 $1,942.44 $1,651.07 $2,767.98
One Child
Two Children
Three or More
Healthfirst HMO A Child-Only 91237NY0020049 Child-Only $382.86 $765.72 $1,148.58
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Gold
Applicable Form Numbers: HF-STDIND-21-OFF, HF-GSOB-21-OFF
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst HMO B 91237NY0020035 Standard, Age 26 $738.27 $1,476.54 $1,255.06 $2,104.07
Healthfirst HMO B, Age 29 Rider 91237NY0020036 Standard, Age 29 $745.63 $1,491.26 $1,267.57 $2,125.05
Healthfirst HMO B-VAD 91237NY0020065 Non-Standard, Age 26 $771.23 $1,542.46 $1,311.09 $2,198.01
Healthfirst HMO B-VAD, Age 29 Rider 91237NY0020066 Non-Standard, Age 29 $778.94 $1,557.88 $1,324.20 $2,219.98
One Child
Two Children
Three or More
Healthfirst HMO B Child-Only 91237NY0020047 Child-Only $304.17 $608.34 $912.51
Silver
Applicable Form Numbers: HF-STDIND-21-OFF, HF-SSOB-21-OFF
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst HMO C 91237NY0020031 Standard, Age 26 $611.17 $1,222.34 $1,038.99 $1,741.83
Healthfirst HMO C, Age 29 Rider 91237NY0020032 Standard, Age 29 $617.29 $1,234.58 $1,049.39 $1,759.28
Healthfirst HMO C-VAD 91237NY0020063 Non-Standard, Age 26 $636.70 $1,273.40 $1,082.39 $1,814.60
Healthfirst HMO C-VAD, Age 29 Rider 91237NY0020064 Non-Standard, Age 29 $643.08 $1,286.16 $1,093.24 $1,832.78
One Child
Two Children
Three or More
Healthfirst HMO C Child-Only 91237NY0020045 Child-Only $251.81 $503.62 $755.43
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Bronze
Applicable Form Numbers: HF-STDIND-21-OFF, HF-BSOB-21-OFF
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst HMO D 91237NY0020027 Standard, Age 26 $457.26 $914.52 $777.34 $1,303.19
Healthfirst HMO D, Age 29 Rider 91237NY0020028 Standard, Age 29 $461.81 $923.62 $785.08 $1,316.16
Healthfirst HMO D-VAD 91237NY0020061 Non-Standard, Age 26 $473.15 $946.30 $804.36 $1,348.48
Healthfirst HMO D-VAD, Age 29 Rider 91237NY0020062 Non-Standard, Age 29 $477.90 $955.80 $812.43 $1,362.02
One Child
Two Children
Three or More
Healthfirst HMO D Child-Only 91237NY0020043 Child-Only $188.38 $376.76 $565.14
Catastrophic
Applicable Form Numbers: HF-STDCC-21-OFF, HF-CCSOB-21-OFF
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst HMO E 91237NY0020069 Standard, Age 26 $282.07 $564.14 $479.52 $803.90
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Section II.B – Rate Pages: Off-Exchange Standard & Non-Standard Plans –Rating Region #8
HEALTHFIRST PHSP, INC. OFF-EXCHANGE INDIVIDUAL HMO STANDARD & NON-STANDARD PLANS
RATE PAGES - EFFECTIVE JANUARY 1, 2021 AREA: Long Island Rating Region (NASSAU & SUFFOLK COUNTIES) - Rating Region #8
Platinum
Applicable Form Numbers: HF-STDIND-21-OFF, HF-PSOB-21-OFF
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst HMO A 91237NY0020039 Standard, Age 26 $929.26 $1,858.52 $1,579.74 $2,648.39
Healthfirst HMO A, Age 29 Rider 91237NY0020040 Standard, Age 29 $938.55 $1,877.10 $1,595.54 $2,674.87
Healthfirst HMO A-VAD 91237NY0020067 Non-Standard, Age 26 $961.61 $1,923.22 $1,634.74 $2,740.59
Healthfirst HMO A-VAD, Age 29 Rider 91237NY0020068 Non-Standard, Age 29 $971.22 $1,942.44 $1,651.07 $2,767.98
One Child
Two Children
Three or More
Healthfirst HMO A Child-Only 91237NY0020049 Child-Only $382.86 $765.72 $1,148.58
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Gold
Applicable Form Numbers: HF-STDIND-21-OFF, HF-GSOB-21-OFF
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst HMO B 91237NY0020035 Standard, Age 26 $738.27 $1,476.54 $1,255.06 $2,104.07
Healthfirst HMO B, Age 29 Rider 91237NY0020036 Standard, Age 29 $745.63 $1,491.26 $1,267.57 $2,125.05
Healthfirst HMO B-VAD 91237NY0020065 Non-Standard, Age 26 $771.23 $1,542.46 $1,311.09 $2,198.01
Healthfirst HMO B-VAD, Age 29 Rider 91237NY0020066 Non-Standard, Age 29 $778.94 $1,557.88 $1,324.20 $2,219.98
One Child
Two Children
Three or More
Healthfirst HMO B Child-Only 91237NY0020047 Child-Only $304.17 $608.34 $912.51
Silver
Applicable Form Numbers: HF-STDIND-21-OFF, HF-SSOB-21-OFF
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst HMO C 91237NY0020031 Standard, Age 26 $611.17 $1,222.34 $1,038.99 $1,741.83
Healthfirst HMO C, Age 29 Rider 91237NY0020032 Standard, Age 29 $617.29 $1,234.58 $1,049.39 $1,759.28
Healthfirst HMO C-VAD 91237NY0020063 Non-Standard, Age 26 $636.70 $1,273.40 $1,082.39 $1,814.60
Healthfirst HMO C-VAD, Age 29 Rider 91237NY0020064 Non-Standard, Age 29 $643.08 $1,286.16 $1,093.24 $1,832.78
One Child
Two Children
Three or More
Healthfirst HMO C Child-Only 91237NY0020045 Child-Only $251.81 $503.62 $755.43
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Bronze
Applicable Form Numbers: HF-STDIND-21-OFF, HF-BSOB-21-OFF
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst HMO D 91237NY0020027 Standard, Age 26 $457.26 $914.52 $777.34 $1,303.19
Healthfirst HMO D, Age 29 Rider 91237NY0020028 Standard, Age 29 $461.81 $923.62 $785.08 $1,316.16
Healthfirst HMO D-VAD 91237NY0020061 Non-Standard, Age 26 $473.15 $946.30 $804.36 $1,348.48
Healthfirst HMO D-VAD, Age 29 Rider 91237NY0020062 Non-Standard, Age 29 $477.90 $955.80 $812.43 $1,362.02
One Child
Two Children
Three or More
Healthfirst HMO D Child-Only 91237NY0020043 Child-Only $188.38 $376.76 $565.14
Catastrophic
Applicable Form Numbers: HF-STDCC-21-OFF, HF-CCSOB-21-OFF
Premium Per Month
Product HIOS ID Product Description Single Single + Spouse
Single + Child(ren)
Single + Spouse + Child(ren)
Healthfirst HMO E 91237NY0020069 Standard, Age 26 $282.07 $564.14 $479.52 $803.90
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SECTION III
Rating Factors, Rate Calculations, Loss Ratios, & Commissions/Fees
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Section III.A – Description of Rating Classes, Factors, & Premium Discounts
Census Tiers Cost Factor
Single 1.000
Single + Spouse 2.000
Single + Child(ren) 1.700
Single + Spouse + Child(ren) 2.850
Child Only 0.412
Rating Region Counties Included Area Factor
New York City (#4) Bronx, Kings, New York, Queens, Richmond,
Westchester, Rockland
1.000
Long Island (#8) Nassau, Suffolk 1.000
Dependent Age Limit Cost Factor
26 1.000
29 1.010
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Section III.B – Rate Calculation Example
Healthfirst premium rates are developed in accordance with New York’s community rating law, and
without any discounts or surcharge factors. Healthfirst’s plans are offered in Rating Regions 4 (NYC) & 8
(Long Island).
EXAMPLE:
Consumer Profile:
• Census Tier: A single, individual subscriber
• Residence: Richmond County (New York City Rating Region #4)
• Plan: Healthfirst Gold Leaf Standard Plan, not choosing the Age 29 Rider.
Rate look-up solution:
One would proceed to page 5 and refer to the table listing Gold-level plans. Next, one would refer to the row labeled, “Healthfirst Gold Leaf” and cross-reference the row labeled, “Single.” The rate for this plan is $775.17 per month.
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Section III.C – Expected Loss Ratios
The projected loss ratio using the Federal medical loss ratio (MLR) methodology is 84.9%. The expected
loss ratio under New York State’s MLR methodology is 83.5%.
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Section III.D – Broker/Agent Commissions & Fees
The products and plans listed herein do not include any consideration related to broker/agent
commissions and/or fees. Brokers/agents who sell these products and plans, accordingly, will not be
compensated by Healthfirst for such sale.
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SECTION IV
Description of Benefits, Types of Coverage, Limitations, Exclusions, Issue Limits,
& Renewal Conditions
*Note: the standard benefit description grid applies to all standard individual on- and off-exchange plans.
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Section III. A – Healthfirst Standard Plans Benefit Description (On & Off Exchange)
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Section III. B – 2021 Non-Standard Plan Benefit Descriptions (On- and Off-Exchange)
Platinum Leaf Premier/HMO A VAD Gold Leaf Premier/HMO B VAD
Individual Deductible $0 $900
Max Out of Pocket (Individual)
$2,000 $6,000
Primary Care Doctor Visit $10 copayment $20 copayment
Specialist Doctor Visit $40 copayment $40 copayment after deductible
Emergency Room (Cost sharing waived if admitted)
$100 copayment $175 copayment after deductible
Ambulatory Surgical Center Facility Fee
$100 copayment $100 copayment after deductible
Lab Diagnostic Office: PCP -$10 copayment SPC -$40 copayment Outpatient Hospital Services: $40 copayment
Office: PCP - $20 copayment SPC -$40 copayment Outpatient Hospital Services: $40 copayment
Inpatient Hospital Services [and Birthing Center]
$500 copayment per admission $1,000 copayment after deductible per Admission
Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy)
$25 copayment $30 copayment after deductible
Skilled Nursing Facility 200 days per plan year
$500 copayment per admission $1,000 copayment after deductible per Admission
Inpatient Habilitation Services (Physical, Speech & Occupational therapy)
$500 copayment per admission $1,000 copayment after deductible per Admission
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Platinum Leaf Premier/HMO A VAD Gold Leaf Premier/HMO B VAD
Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy)
$500 copayment per admission $1,000 copayment after deductible per Admission
Mental Health/Substance Abuse - Inpatient
$500 copayment per admission $1,000 copayment after deductible per Admission
Mental Health/Substance Abuse - Outpatient / Behavioral Health
$10 copayment $20 copayment
Retail Generic Drugs (Tier 1) $5 copayment $7 copayment
Retail Preferred Drugs (Tier 2) $50 copayment $50 copayment
Retail Non-Preferred Drugs (Tier 3) $85 copayment $100 copayment
Silver Leaf Premier/HMO C VAD Silver Leaf 200‐250 Premier
Individual Deductible $4,650 $3,500
Max Out of Pocket (Individual)
$8,700 $8,500
Primary Care Doctor Visit $30 copayment $30 copayment
Specialist Doctor Visit $55 copayment after deductible $55 copayment after deductible
Emergency Room (Cost sharing waived if admitted)
$250 copayment after deductible $250 copayment after deductible
Ambulatory Surgical Center Facility Fee
$100 copayment after deductible $100 copayment after deductible
Lab Diagnostic Office: PCP - $30 copayment SPC -$55 copayment Outpatient Hospital Services: $55 copayment
Office: PCP - $30 copayment SPC -$55 copayment Outpatient Hospital Services: $55 copayment
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Silver Leaf Premier/HMO C VAD Silver Leaf 200‐250 Premier
Inpatient Hospital Services [and Birthing Center]
$1,500 copayment after deductible per admission
$1,500 copayment after deductible per admission
Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy)
$55 copayment after deductible $55 copayment after deductible
Skilled Nursing Facility 200 days per plan year
$1,500 copayment after deductible per admission
$1,500 copayment after deductible per admission
Inpatient Habilitation Services (Physical, Speech & Occupational therapy)
$1,500 copayment after deductible per admission
$1,500 copayment after deductible per admission
Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy)
$1,500 copayment after deductible per admission
$1,500 copayment after deductible per admission
Mental Health/Substance Abuse - Inpatient
$1,500 copayment after deductible per admission
$1,500 copayment after deductible per admission
Mental Health/Substance Abuse - Outpatient / Behavioral Health
$30 copayment $30 copayment
Retail Generic Drugs (Tier 1) $10 copayment $10 copayment
Retail Preferred Drugs (Tier 2) $55 copayment $55 copayment
Retail Non-Preferred Drugs (Tier 3) $100 copayment $100 copayment
Bronze Leaf Premier/HMO B VAD Native American CSR Premier
(all Metal Levels)
Individual Deductible $5,150 $0
Max Out of Pocket (Individual)
$8,550 $0
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____________________________________________________________________________________ Healthfirst PHSP, Inc. 2021 Rate Manual; Individual Market Page 29 of 31
Bronze Leaf Premier/HMO B VAD Native American CSR Premier
(all Metal Levels)
Primary Care Doctor Visit $45 copayment Covered in full
Specialist Doctor Visit 65% Coinsurance after deductible Covered in full
Emergency Room (Cost sharing waived if admitted)
65% Coinsurance after deductible Covered in full
Ambulatory Surgical Center Facility Fee
65% Coinsurance after deductible Covered in full
Lab Diagnostic 65% Coinsurance after deductible Covered in full
Inpatient Hospital Services [and Birthing Center]
65% Coinsurance after deductible Covered in full
Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy)
65% Coinsurance after deductible Covered in full
Skilled Nursing Facility 200 days per plan year
65% Coinsurance after deductible Covered in full
Inpatient Habilitation Services (Physical, Speech & Occupational therapy)
65% Coinsurance after deductible Covered in full
Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy)
65% Coinsurance after deductible Covered in full
Mental Health/Substance Abuse - Inpatient
65% Coinsurance after deductible Covered in full
Mental Health/Substance Abuse - Outpatient / Behavioral Health
$45 copayment Covered in full
Retail Generic Drugs (Tier 1) $8 copayment after deductible Covered in full
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____________________________________________________________________________________ Healthfirst PHSP, Inc. 2021 Rate Manual; Individual Market Page 30 of 31
Bronze Leaf Premier/HMO B VAD Native American CSR Premier
(all Metal Levels)
Retail Preferred Drugs (Tier 2) $60 copayment after deductible Covered in full
Retail Non-Preferred Drugs (Tier 3) $95 copayment after deductible Covered in full