Transcription
Independent Health Benefits CorporationIndependent Health's Individual Rate ManualFor Plans Offered On and Off New York State's Health Insurance ExchangeEffective January 1, 2021
Independent Health Benefits Corporation511 Farber Lakes DriveBuffalo, NY 14221Independent Health's Individual Rate ManualFor Plans Offered On and Off the NYS Health Insurance ExchangeTable of ContentsSectionDescriptionPagesA.Broker Commissions1B.ELR2C.Counties3D.Premium Calculation4E.Benefit GridsF.Premium RatesTable of Contents5-910-12
Independent Health Benefits Corporation511 Farber Lakes DriveBuffalo, NY 14221Independent Health's Individual Rate ManualFor Plans Offered On and Off the NYS Health Insurance ExchangeCommission Schedule AIndividual Market (On & Off Exchange)- 25 per contract per month (PCPM) paid for each Individual contract On/Off Exchange- Notification of broker of record designation must be received with the individual enrollment formBroker must be included on the New York State of Health file feed in order to qualify for commission payment on individual contractswritten through the New York State of Health.- Commissions will be paid after receipt of premium- Commissions will be paid quarterly- Individual contracts are not included in New Business and Net Retention Bonuses1
Independent Health Benefits Corporation511 Farber Lakes DriveBuffalo, NY 14221Independent Health's Individual Rate ManualFor Plans Offered On and Off the NYS Health Insurance ExchangeExpected Loss RatioIndividual Market (On & Off Exchange)The expected loss ratio is calculated using the traditional New York State methodology as outlined in Circular Letter15 from /cl2011 15.htmIndependent Health's Individual Market's loss ratio is expected to be 85.2% which is greater than the required minimum lossratio of 82%.2
Independent Health Benefits Corporation511 Farber Lakes DriveBuffalo, NY 14221Independent Health's Individual Rate ManualFor Plans Offered On and Off the NYS Health Insurance ExchangeRating Region & Applicable CountiesIndividual Market (On & Off Exchange)The rating region for this rate manual is the Western New York service Area (Buffalo Area).These counties include Erie, Niagara, Orleans, Genesee, Wyoming, Chautauqua, Cattaraugus and Allegany.Certain products, as noted in the Benefit Grids, are only available for sale in a subset of the 8 counties.3
Independent Health Benefits Corporation511 Farber Lakes DriveBuffalo, NY 14221Independent Health's Individual Rate ManualFor Plans Offered On and Off the NYS Health Insurance ExchangePremium Calculation ExampleSlope Adjustment Factors:Child Only RateAdmin :Profit:Health Insurance Provider Fee:2020 Risk Adjustment User Fee PMPM:PCORI PMPM:DFS Adjustment Factor:41.20%13.26%1.50%0.00% 0.19 0.2398.26%Standard PlatinumFlexFit PlatinumChoice Plus PlatinumStandard GoldiDirect Gold CopayiDirect Gold Copay HSAQMax GoldStandard SilverMax SilveriDirect Silver Copay HSAQChoice Plus Silver HSAQStandard Bronze HSAQiDirect Bronze Coinsurance HSAQiDirect Bronze MVStandard .9394740.8843770.88437711.0671.70Employee ChildConversion FactorsHIOS IDRate ManualRates Effective January 1, 202118029NY1180001-00Standard Platinum18029NY1180001-01Standard Platinum18029NY1180001-02Standard Platinum AN/AI 300% FPL18029NY1180001-03Standard Platinum AN/AI 300% FPL18029NY1180002-00Standard Platinum18029NY1180002-01Standard Platinum18029NY1180002-02Standard Platinum AN/AI 300% FPL18029NY1180002-03Standard Platinum AN/AI 300% FPL18029NY1180008-00Standard Platinum18029NY1180009-00Standard Platinum (Child Only)18029NY1180009-01Standard Platinum (Child Only)18029NY1180009-02Standard Platinum AN/AI 300% FPL (Child Only)18029NY1180009-03Standard Platinum AN/AI 300% FPL (Child Only)18029NY1180010-00Standard Platinum18029NY1180012-00Standard Platinum (Child Only)4Product ONet Claim Cost as ofJan 1, 2021 566.27 566.27 566.27 566.27 571.73 571.73 571.73 571.73 566.27 566.27 566.27 566.27 566.27 571.73 566.27Single 788.68 788.68 788.68 788.68 796.28 796.28 796.28 796.28 788.68 788.68 788.68 788.68 788.68 796.28 788.68 1,340.76 1,340.76 1,340.76 1,340.76 1,353.68 1,353.68 1,353.68 1,353.68 1,340.76N/AN/AN/AN/A 1,353.68N/A2.002.850.412DoubleFamilyChild Only 1,577.36 1,577.36 1,577.36 1,577.36 1,592.56 1,592.56 1,592.56 1,592.56 1,577.36N/AN/AN/AN/A 1,592.56N/A 2,247.74 2,247.74 2,247.74 2,247.74 2,269.40 2,269.40 2,269.40 2,269.40 2,247.74N/AN/AN/AN/A 2,269.40N/AN/AN/AN/AN/AN/AN/AN/AN/AN/A 324.94 324.94 324.94 324.94N/A 324.94
Platinum Plans5Standard PlatinumFlexFit PlatinumChoice Plus PlatinumIn-Network Deductible 0 0Integrated Medical and Drug DeductibleNoNoIn-Network Coinsurance0%0%In-Network OOP Maximum 2,000 5,250Emergency Room Services 100 150All Inpatient Hospital Services (inc. MHSA) 500 500Primary Care Visit to Treat an injury or Illness(exc. Preventive, and X-ray) 15 10Specialist Visit 35 40Mental/Behavioral Health and Substance AbuseDisorder Outpatient Services 15 10Imaging (CT/PET Scans, MRIs) 35 85Rehabilitative Speech Therapy 25 40Rehabilitative Occupational and RehabilitativePhysician Therapy 25 40Laboratory Outpatient and Professional Services 35 10X-ray and Diagnostic Imaging 35 40Skilled Nursing Facility 500 500Outpatient Facility Fee 100 75Outpatient Surgery Physician/Surgical Services 100 0GenericsPreferred Brand DrugsNon-Preferred Brand DrugsSpecialty Drugs (i.e., high cost) 10 30 60 10 / 30 / 60 5 3050% 5 / 30 / 50%A: 0B: 1,500NoA: 0%B: 50%A: 5,250B: 5,250A: 150B: 150A: 500B: 50% After DeductibleA: 10B: 50% After DeductibleA: 40B: 50% After DeductibleA: 10B: 50% After DeductibleA: 85B: 50% After DeductibleA: 40B: 50% After DeductibleA: 40B: 50% After DeductibleA: 10B: 50% After DeductibleA: 40B: 50% After DeductibleA: 500B: 50% After DeductibleA: 75B: 50% After DeductibleA: 0B: 50% After Deductible 5 3050% 5 / 30 / 50%Out-of-Network DeductibleOut-of-Network CoinsuranceOON OOP MaximumRegion Available 5,00050%UnlimitedAll 8 WNY 5,00050%UnlimitedAll 8 WNY 5,00050%UnlimitedErie, Niagara
Gold PlansStandard GoldiDirect Gold CopayMax GoldiDirect Gold Copay HSAQIn-Network DeductibleIntegrated Medical and Drug DeductibleIn-Network CoinsuranceIn-Network OOP MaximumEmergency Room ServicesAll Inpatient Hospital Services (inc. MHSA)Primary Care Visit to Treat an injury or Illness (exc.Preventive, and X-ray)Specialist VisitMental/Behavioral Health and Substance AbuseDisorder Outpatient ServicesImaging (CT/PET Scans, MRIs)Rehabilitative Speech TherapyRehabilitative Occupational and Rehabilitative PhysicianTherapyLaboratory Outpatient and Professional ServicesX-ray and Diagnostic ImagingSkilled Nursing FacilityOutpatient Facility FeeOutpatient Surgery Physician/Surgical ServicesGenericsPreferred Brand DrugsNon-Preferred Brand Drugs 600No0% 4,000 150 After Deductible 1,000 After Deductible 1,250No0% 6,750 150 1,000 After Deductible 1,500Yes0% 6,750 150 1,000 After Deductible 1,400Yes0% 6,750 150 After Deductible 1,000 After Deductible 25 After Deductible 20 20 20 After Deductible 40 After Deductible 50 After Deductible 50 After Deductible 50 After Deductible 25 After Deductible 20 20 20 After Deductible 40 After Deductible 30 After Deductible 85 After Deductible 50 After Deductible 85 After Deductible 50 After Deductible 85 After Deductible 50 After Deductible 30 After Deductible 50 After Deductible 50 After Deductible 50 After Deductible 40 After Deductible 40 After Deductible 1,000 After Deductible 100 After Deductible 100 After Deductible 10 35 70 20 After Deductible 50 1,000 After Deductible 75 After Deductible 0 After Deductible 10 4050%Specialty Drugs (i.e., high cost) 10 / 35 / 70 10 / 40 / 50% 20 After Deductible 50 1,000 After Deductible 75 After Deductible 0 After Deductible 10 40 After Deductible50% After Deductible 10 / 40 After Deductible / 50% AfterDeductible 20 After Deductible 50 After Deductible 1,000 After Deductible 75 After Deductible 0 After Deductible 10 After Deductible 40 After Deductible50% After Deductible 10 After Deductible / 40 AfterDeductible / 50% After DeductibleOut-of-Network DeductibleOut-of-Network CoinsuranceOON OOP MaximumRegion Available 5,00050%UnlimitedAll 8 WNY 5,00050%UnlimitedAll 8 WNY 5,00050%UnlimitedAll 8 WNY 5,00050%UnlimitedAll 8 WNY6
Silver PlansStandard SilveriDirect Silver Copay HSAQ 1,300 2,250Integrated Medical and Drug DeductibleNoYesIn-Network Coinsurance0%0%In-Network OOP Maximum 8,500 6,950Emergency Room Services 300 After Deductible 250 After DeductibleAll Inpatient Hospital Services (inc. MHSA) 1,500 After Deductible 1,000 After DeductiblePrimary Care Visit to Treat an injury or Illness (exc. Preventive,and X-ray) 30 After Deductible 35 After DeductibleSpecialist Visit 50 After Deductible 60 After DeductibleMental/Behavioral Health and Substance Abuse DisorderOutpatient Services 30 After Deductible 35 After DeductibleImaging (CT/PET Scans, MRIs) 75 After Deductible 85 After DeductibleRehabilitative Speech Therapy 30 After Deductible 60 After DeductibleRehabilitative Occupational and Rehabilitative PhysicianTherapy 30 After Deductible 60 After DeductibleLaboratory Outpatient and Professional Services 50 After Deductible 35 After DeductibleX-ray and Diagnostic Imaging 75 After Deductible 60 After DeductibleSkilled Nursing Facility 1,500 After Deductible 1,000 After DeductibleOutpatient Facility Fee 150 After Deductible 100 After DeductibleOutpatient Surgery Physician/Surgical Services 150 After Deductible 0 After DeductibleGenericsPreferred Brand DrugsNon-Preferred Brand Drugs 10 35 70Specialty Drugs (i.e., high cost) 10 / 35 / 70 15 After Deductible 50 After Deductible50% After Deductible 15 After Deductible / 50After Deductible / 50% AfterDeductibleA: 2,250B: 3,750YesA: 0%B: 50%A: 6,950B: 6,950A: 250 After DeductibleB: 250 After DeductibleA: 1,000 After DeductibleB: 50% After DeductibleA: 35 After DeductibleB: 50% After DeductibleA: 60 After DeductibleB: 50% After DeductibleA: 35 After DeductibleB: 50% After DeductibleA: 85 After DeductibleB: 50% After DeductibleA: 60 After DeductibleB: 50% After DeductibleA: 60 After DeductibleB: 50% After DeductibleA: 35 After DeductibleB: 50% After DeductibleA: 60 After DeductibleB: 50% After DeductibleA: 1,000 After DeductibleB: 50% After DeductibleA: 100 After DeductibleB: 50% After DeductibleA: 0 After DeductibleB: 50% After Deductible 15 After Deductible 50 After Deductible50% After Deductible 15 After Deductible / 50After Deductible / 50% AfterDeductibleOut-of-Network DeductibleOut-of-Network CoinsuranceOON OOP MaximumRegion Available 5,00050%UnlimitedAll 8 WNY 5,00050%UnlimitedAll 8 WNY 5,00050%UnlimitedErie, NiagaraIn-Network Deductible7Choice Plus Silver HSAQMax Silver 2,800Yes0% 7,550 250 After Deductible 1,000 After Deductible 35 60 After Deductible 35 85 After Deductible 60 After Deductible 60 After Deductible 35 After Deductible 60 After Deductible 1,000 After Deductible 200 After Deductible 150 After Deductible 15 50 After Deductible50% After Deductible 15 / 50 After Deductible /50% After Deductible 5,00050%UnlimitedAll 8 WNY
Bronze PlansStandard Bronze HSAQiDirect Bronze Coinsurance HSAQiDirect Bronze MV 6,100Yes50% 6,90050% After Deductible50% After Deductible 5,600Yes50% 6,95050% After Deductible50% After Deductible 8,550Yes0% 8,550 0 After Deductible 0 After Deductible50% After Deductible50% After Deductible 0 After Deductible50% After Deductible50% After Deductible 0 After Deductible50% After Deductible50% After Deductible 0 After Deductible50% After Deductible50% After Deductible50% After Deductible50% After Deductible 0 After Deductible 0 After Deductible50% After Deductible50% After Deductible 0 After Deductible50% After Deductible50% After Deductible50% After Deductible50% After Deductible50% After Deductible 10 After Deductible 35 After Deductible 70 After Deductibe50% After Deductible50% After Deductible50% After Deductible50% After Deductible50% After Deductible50% After Deductible50% After Deductible50% After Deductible 0 After Deductible 0 After Deductible 0 After Deductible 0 After Deductible 0 After Deductible 0 After Deductible 0 After Deductible 0 After DeductibleSpecialty Drugs (i.e., high cost) 10 After Deductible / 35 AfterDeductible / 70 After Deductibe50% After Deductible 0 After DeductibleOut-of-Network DeductibleOut-of-Network CoinsuranceOON OOP MaximumRegion Available 5,00050%UnlimitedAll 8 WNY 7,50050%UnlimitedAll 8 WNY 10,00050%UnlimitedAll 8 WNYIn-Network DeductibleIntegrated Medical and Drug DeductibleIn-Network CoinsuranceIn-Network OOP MaximumEmergency Room ServicesAll Inpatient Hospital Services (inc. MHSA)Primary Care Visit to Treat an injury or Illness (exc.Preventive, and X-ray)Specialist VisitMental/Behavioral Health and Substance AbuseDisorder Outpatient ServicesImaging (CT/PET Scans, MRIs)Rehabilitative Speech TherapyRehabilitative Occupational and RehabilitativePhysician TherapyLaboratory Outpatient and Professional ServicesX-ray and Diagnostic ImagingSkilled Nursing FacilityOutpatient Facility FeeOutpatient Surgery Physician/Surgical ServicesGenericsPreferred Brand DrugsNon-Preferred Brand Drugs8
Catastrophic PlansStandard CatastrophicIn-Network DeductibleIntegrated Medical and Drug DeductibleIn-Network CoinsuranceIn-Network OOP MaximumEmergency Room ServicesAll Inpatient Hospital Services (inc. MHSA)Primary Care Visit to Treat an injury or Illness (exc. Preventive, and X-ray)Specialist Visit 8,550Yes0% 8,550 0 After Deductible 0 After Deductible 0 After Deductible After 3 visits for Primary Care Allowance 0 After DeductibleMental/Behavioral Health and Substance Abuse Disorder Outpatient Services 0 After DeductibleImaging (CT/PET Scans, MRIs)Rehabilitative Speech TherapyRehabilitative Occupational and Rehabilitative Physician TherapyLaboratory Outpatient and Professional ServicesX-ray and Diagnostic ImagingSkilled Nursing FacilityOutpatient Facility FeeOutpatient Surgery Physician/Surgical ServicesGenericsPreferred Brand DrugsNon-Preferred Brand DrugsSpecialty Drugs (i.e., high cost) 0 After Deductible 0 After Deductible 0 After Deductible 0 After Deductible 0 After Deductible 0 After Deductible 0 After Deductible 0 After Deductible 0 After Deductible 0 After Deductible 0 After Deductible 0 After DeductibleOut-of-Network DeductibleOut-of-Network CoinsuranceOON OOP MaximumRegion AvailableN/A100%UnlimitedAll 8 WNY9
Independent Health Benefits CorporationIndividual On Exchange Premium Rates Effective January 1, 2021Form NumbersHIOS Plan IDBase FormSchedule of Age 18029NY1220009-01Marketing NameProduct Description11.722.852.85SingleEmployee Child(ren)Employee SpouseFamilyChild OnlyON On ExchangeIN IndividualDEP25 Dependents to 26DEP29 Dependents to 30SNF200 Skilled Nursing Facility 200 days maxSNF365 Unlimited Skilled Nursing FacilityDPY Domestic PartnerFPY Family PlanningCO Child OnlyDomesticPartnerUnlimitedRiderSNF RiderPlatinum PlansStandard PlatinumStandard Platinum (AN/AI 300% FPL)Standard Platinum (AN/AI 300% FPL)Standard PlatinumStandard Platinum (AN/AI 300% FPL)Standard Platinum (AN/AI 300% FPL)Standard PlatinumStandard Platinum (AN/AI 300% FPL)Standard Platinum (AN/AI 300% FPL)FlexFit PlatinumFlexFit Platinum (AN/AI 300% FPL)FlexFit Platinum (AN/AI 300% FPL)FlexFit PlatinumFlexFit Platinum (AN/AI 300% FPL)FlexFit Platinum (AN/AI 300% NF365.DPY.FPYONIN.DEP29.SNF365.DPY.FPY 788.68 788.68 788.68 796.28 796.28 796.28N/AN/AN/A 730.97 730.97 730.97 738.01 738.01 738.01 1,340.76 1,340.76 1,340.76 1,353.68 1,353.68 1,353.68N/AN/AN/A 1,242.65 1,242.65 1,242.65 1,254.62 1,254.62 1,254.62 1,577.36 1,577.36 1,577.36 1,592.56 1,592.56 1,592.56N/AN/AN/A 1,461.94 1,461.94 1,461.94 1,476.02 1,476.02 1,476.02 2,247.74 2,247.74 2,247.74 2,269.40 2,269.40 2,269.40N/AN/AN/A 2,083.26 2,083.26 2,083.26 2,103.33 2,103.33 2,103.33N/AN/AN/AN/AN/AN/A 324.94 324.94 324.94N/AN/AN/AN/AN/AN/AIHBC-R1065Standard GoldONIN.DEP25.SNF200.DPY.FPY 650.93 1,106.58 1,301.86 1,855.15N/AIHBC-R1065Standard Gold (AN/AI 300% FPL)ONIN.DEP25.SNF200.DPY.FPY 650.93 1,106.58 1,301.86 1,855.15N/AIHBC-R1065Standard Gold (AN/AI 300% FPL)ONIN.DEP25.SNF200.DPY.FPY 650.93 1,106.58 1,301.86 1,855.15N/AIHBC-R1064IHBC-R1065Standard GoldONIN.DEP29.SNF200.DPY.FPY 657.19 1,117.22 1,314.38 d Gold (AN/AI 300% FPL)ONIN.DEP29.SNF200.DPY.FPY 657.19 1,117.22 1,314.38 Standard Gold (AN/AI 300% FPL)ONIN.DEP29.SNF200.DPY.FPY 657.19 1,117.22 1,314.38 d GoldONIN.DEP20.SNF200.DPY.FPY.CON/AN/AN/AN/A R1065Standard Gold (AN/AI 300% FPL)ONIN.DEP20.SNF200.DPY.FPY.CON/AN/AN/AN/A R1065Standard Gold (AN/AI 300% FPL)ONIN.DEP20.SNF200.DPY.FPY.CON/AN/AN/AN/A R1065IHBC-R2014iDirect Gold Copay HSAQONIN.DEP25.SNF365.DPY.FPY 603.31 1,025.63 1,206.62 IHBC-R1065IHBC-R2014iDirect Gold Copay HSAQ (AN/AI 300% FPL)ONIN.DEP25.SNF365.DPY.FPY 603.31 1,025.63 1,206.62 IHBC-R1065IHBC-R2014iDirect Gold Copay HSAQ (AN/AI 300% FPL)ONIN.DEP25.SNF365.DPY.FPY 603.31 1,025.63 1,206.62 IHBC-R1064IHBC-R1065IHBC-R2014iDirect Gold Copay HSAQONIN.DEP29.SNF365.DPY.FPY 609.12 1,035.50 1,218.24 IHBC-R1064IHBC-R1065IHBC-R2014iDirect Gold Copay HSAQ (AN/AI 300% FPL)ONIN.DEP29.SNF365.DPY.FPY 609.12 1,035.50 1,218.24 IHBC-R1064IHBC-R1065IHBC-R2014iDirect Gold Copay HSAQ (AN/AI 300% FPL)ONIN.DEP29.SNF365.DPY.FPY 609.12 1,035.50 1,218.24 IHBC-R1065IHBC-R2014iDirect Gold CopayONIN.DEP25.SNF365.DPY.FPY 623.27 1,059.56 1,246.54 IHBC-R1065IHBC-R2014iDirect Gold Copay (AN/AI 300% FPL)ONIN.DEP25.SNF365.DPY.FPY 623.27 1,059.56 1,246.54 IHBC-R1065IHBC-R2014iDirect Gold Copay (AN/AI 300% FPL)ONIN.DEP25.SNF365.DPY.FPY 623.27 1,059.56 1,246.54 IHBC-R1064IHBC-R1065IHBC-R2014iDirect Gold CopayONIN.DEP29.SNF365.DPY.FPY 629.28 1,069.78 1,258.56 IHBC-R1064IHBC-R1065IHBC-R2014iDirect Gold Copay (AN/AI 300% FPL)ONIN.DEP29.SNF365.DPY.FPY 629.28 1,069.78 1,258.56 IHBC-R1064IHBC-R1065IHBC-R2014iDirect Gold Copay (AN/AI 300% FPL)ONIN.DEP29.SNF365.DPY.FPY 629.28 1,069.78 1,258.56 IHBC-R1065IHBC-R2014Max GoldONIN.DEP25.SNF365.DPY.FPY 612.62 1,041.45 1,225.24 IHBC-R1065IHBC-R2014Max Gold (AN/AI 300% FPL)ONIN.DEP25.SNF365.DPY.FPY 612.62 1,041.45 1,225.24 IHBC-R1065IHBC-R2014Max Gold (AN/AI 300% FPL)ONIN.DEP25.SNF365.DPY.FPY 612.62 1,041.45 1,225.24 IHBC-R1064IHBC-R1065IHBC-R2014Max GoldONIN.DEP29.SNF365.DPY.FPY 618.51 1,051.47 1,237.02 IHBC-R1064IHBC-R1065IHBC-R2014Max Gold (AN/AI 300% FPL)ONIN.DEP29.SNF365.DPY.FPY 618.51 1,051.47 1,237.02 IHBC-R1064IHBC-R1065IHBC-R2014Max Gold (AN/AI 300% FPL)ONIN.DEP29.SNF365.DPY.FPY 618.51 1,051.47 1,237.02 4IHBC-R2014IHBC-R2014IHBC-R2014Gold PlansN/ASilver 1065Standard SilverONIN.DEP25.SNF200.DPY.FPY 540.19 918.32 1,080.38 IHBC-R1065Standard Silver (AN/AI 300% FPL)ONIN.DEP25.SNF200.DPY.FPY 540.19 918.32 1,080.38 IHBC-R1065Standard Silver (AN/AI 300% FPL)ONIN.DEP25.SNF200.DPY.FPY 540.19 918.32 1,080.38 IHBC-R1065Standard Silver (CSR1)ONIN.DEP25.SNF200.DPY.FPY 540.19 918.32 1,080.38 IHBC-R1065Standard Silver (CSR2)ONIN.DEP25.SNF200.DPY.FPY 540.19 918.32 1,080.38 IHBC-R1065Standard Silver (CSR3)ONIN.DEP25.SNF200.DPY.FPY 540.19 918.32 1,080.38 IHBC-R1064IHBC-R1065Standard SilverONIN.DEP29.SNF200.DPY.FPY 545.39 927.16 1,090.78 IHBC-R1064IHBC-R1065Standard Silver (AN/AI 300% FPL)ONIN.DEP29.SNF200.DPY.FPY 545.39 927.16 1,090.78 IHBC-R1064IHBC-R1065Standard Silver (AN/AI 300% FPL)ONIN.DEP29.SNF200.DPY.FPY 545.39 927.16 1,090.78 IHBC-R1064IHBC-R1065Standard Silver (CSR1)ONIN.DEP29.SNF200.DPY.FPY 545.39 927.16 1,090.78 IHBC-R1064IHBC-R1065Standard Silver (CSR2)ONIN.DEP29.SNF200.DPY.FPY 545.39 927.16 1,090.78 C-R1064IHBC-R1065Standard Silver (CSR3)ONIN.DEP29.SNF200.DPY.FPY 545.39 927.16 1,090.78 IHBC-R1065Standard SilverONIN.DEP20.SNF200.DPY.FPY.CON/AN/AN/AN/A R1065Standard Silver (AN/AI 300% FPL)ONIN.DEP20.SNF200.DPY.FPY.CON/AN/AN/AN/A R1065Standard Silver (AN/AI 300% FPL)ONIN.DEP20.SNF200.DPY.FPY.CON/AN/AN/AN/A R1065Standard Silver (CSR1)ONIN.DEP20.SNF200.DPY.FPY.CON/AN/AN/AN/A R1065Standard Silver (CSR2)ONIN.DEP20.SNF200.DPY.FPY.CON/AN/AN/AN/A R1065Standard Silver (CSR3)ONIN.DEP20.SNF200.DPY.FPY.CON/AN/AN/AN/A R1065IHBC-R2014iDirect Silver Copay HSAQONIN.DEP25.SNF365.DPY.FPY 498.27 847.06 996.54 IHBC-R1065IHBC-R2014iDirect Silver Copay HSAQ (AN/AI 300% FPL)ONIN.DEP25.SNF365.DPY.FPY 498.27 847.06 996.54 IHBC-R1065IHBC-R2014iDirect Silver Copay HSAQ (AN/AI 300% FPL)ONIN.DEP25.SNF365.DPY.FPY 498.27 847.06 996.54 IHBC-R1065IHBC-R2014iDirect Silver Copay HSAQ (CSR1)ONIN.DEP25.SNF365.DPY.FPY 498.27 847.06 996.54 IHBC-R1065IHBC-R2014iDirect Silver Copay HSAQ (CSR2)ONIN.DEP25.SNF365.DPY.FPY 498.27 847.06 996.54 IHBC-R1065IHBC-R2014iDirect Silver Copay HSAQ (CSR3)ONIN.DEP25.SNF365.DPY.FPY 498.27 847.06 996.54 IHBC-R1064IHBC-R1065IHBC-R2014iDirect Silver Copay HSAQONIN.DEP29.SNF365.DPY.FPY 503.06 855.20 1,006.12 IHBC-R1064IHBC-R1065IHBC-R2014iDirect Silver Copay HSAQ (AN/AI 300% FPL)ONIN.DEP29.SNF365.DPY.FPY 503.06 855.20 1,006.12 IHBC-R1064IHBC-R1065IHBC-R2014iDirect Silver Copay HSAQ (AN/AI 300% FPL)ONIN.DEP29.SNF365.DPY.FPY 503.06 855.20 1,006.12 IHBC-R1064IHBC-R1065IHBC-R2014iDirect Silver Copay HSAQ (CSR1)ONIN.DEP29.SNF365.DPY.FPY 503.06 855.20 1,006.12 IHBC-R1064IHBC-R1065IHBC-R2014iDirect Silver Copay HSAQ (CSR2)ONIN.DEP29.SNF365.DPY.FPY 503.06 855.20 1,006.12 IHBC-R1064IHBC-R1065IHBC-R2014iDirect Silver Copay HSAQ (CSR3)ONIN.DEP29.SNF365.DPY.FPY 503.06 855.20 1,006.12 1,433.72N/A10N/A
Independent Health Benefits CorporationIndividual On Exchange Premium Rates Effective January 1, 2021Form NumbersHIOS Plan IDMarketing NameProduct Description11.722.852.85SingleEmployee Child(ren)Employee SpouseFamilyChild OnlyON On ExchangeIN IndividualDEP25 Dependents to 26DEP29 Dependents to 30SNF200 Skilled Nursing Facility 200 days maxSNF365 Unlimited Skilled Nursing FacilityDPY Domestic PartnerFPY Family PlanningCO Child OnlyBase FormSchedule of Age 29BenefitsRiderDomesticPartnerUnlimitedRiderSNF 1065IHBC-R2014Max SilverONIN.DEP25.SNF365.DPY.FPY 500.67 851.14 1,001.34 IHBC-R1065IHBC-R2014Max Silver (AN/AI 300% FPL)ONIN.DEP25.SNF365.DPY.FPY 500.67 851.14 1,001.34 IHBC-R1065IHBC-R2014Max Silver (AN/AI 300% FPL)ONIN.DEP25.SNF365.DPY.FPY 500.67 851.14 1,001.34 IHBC-R1065IHBC-R2014Max Silver (CSR1)ONIN.DEP25.SNF365.DPY.FPY 500.67 851.14 1,001.34 IHBC-R1065IHBC-R2014Max Silver (CSR2)ONIN.DEP25.SNF365.DPY.FPY 500.67 851.14 1,001.34 IHBC-R1065IHBC-R2014Max Silver (CSR3)ONIN.DEP25.SNF365.DPY.FPY 500.67 851.14 1,001.34 IHBC-R1064IHBC-R1065IHBC-R2014Max SilverONIN.DEP29.SNF365.DPY.FPY 505.49 859.33 1,010.98 IHBC-R1064IHBC-R1065IHBC-R2014Max Silver (AN/AI 300% FPL)ONIN.DEP29.SNF365.DPY.FPY 505.49 859.33 1,010.98 IHBC-R1064IHBC-R1065IHBC-R2014Max Silver (AN/AI 300% FPL)ONIN.DEP29.SNF365.DPY.FPY 505.49 859.33 1,010.98 IHBC-R1064IHBC-R1065IHBC-R2014Max Silver (CSR1)ONIN.DEP29.SNF365.DPY.FPY 505.49 859.33 1,010.98 IHBC-R1064IHBC-R1065IHBC-R2014Max Silver (CSR2)ONIN.DEP29.SNF365.DPY.FPY 505.49 859.33 1,010.98 IHBC-R1064IHBC-R1065IHBC-R2014Max Silver (CSR3)ONIN.DEP29.SNF365.DPY.FPY 505.49 859.33 1,010.98 1,440.65N/ABronze 1065Standard BronzeONIN.DEP25.SNF200.DPY.FPY 409.63 696.37 819.26 IHBC-R1065Standard Bronze (AN/AI 300% FPL)ONIN.DEP25.SNF200.DPY.FPY 409.63 696.37 819.26 IHBC-R1065Standard Bronze (AN/AI 300% FPL)ONIN.DEP25.SNF200.DPY.FPY 409.63 696.37 819.26 IHBC-R1064IHBC-R1065Standard BronzeONIN.DEP29.SNF200.DPY.FPY 413.57 703.07 827.14 IHBC-R1064IHBC-R1065Standard Bronze (AN/AI 300% FPL)ONIN.DEP29.SNF200.DPY.FPY 413.57 703.07 827.14 IHBC-R1064IHBC-R1065Standard Bronze (AN/AI 300% FPL)ONIN.DEP29.SNF200.DPY.FPY 413.57 703.07 827.14 IHBC-R1065Standard BronzeONIN.DEP20.SNF200.DPY.FPY.CON/AN/AN/AN/A R1065Standard Bronze (AN/AI 300% FPL)ONIN.DEP20.SNF200.DPY.FPY.CON/A R1065Standard Bronze (AN/AI 300% FPL)ONIN.DEP20.SNF200.DPY.FPY.CON/AN/AN/AN/A R1065IHBC-R2014iDirect Bronze Coinsurance HSAQONIN.DEP25.SNF365.DPY.FPY 385.52 655.38 771.04 IHBC-R1065IHBC-R2014iDirect Bronze Coinsurance HSAQ (AN/AI 300% FPL)ONIN.DEP25.SNF365.DPY.FPY 385.52 655.38 771.04 IHBC-R1065IHBC-R2014iDirect Bronze Coinsurance HSAQ (AN/AI 300% FPL)ONIN.DEP25.SNF365.DPY.FPY 385.52 655.38 771.04 1,098.73N/A18029NY1310034-01IHB
Standard Gold iDirect Gold Copay Max Gold iDirect Gold Copay HSAQ In-Network Deductible 600 1,250 1,500 1,400 Integrated Medical and Drug Deductible No No Yes Yes In-Network Coinsurance 0% 0% 0% 0% In-Network OOP Maximum 4,000 6,750 6,750 6,750 Emergency Room Services 150 After Deductible 150 150 150 After Deductible
