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Individual Policy & Schedule of Benefits

To view the Individual Policy and Schedule of Benefits you are interested in, select the applicable plan name below.

You are now viewing 2022 plan year

View Plan year: 2021

ON-EXCHANGE

Silver 2022

Plan Individual Policy Schedule of Benefits Effective Date
Silver Plan AH1 PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan AH1 - 73% PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan AH1 - 87% PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan AH1 - 94% POS Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 1 PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 1 - 73% PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 1 - 87% PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 1 - 94% PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan HSA 1 Individual Policy Schedule of Benefits 1/1/2022
Silver Plan HSA 1 - 73% PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan HSA 1 - 87% PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan HSA 1 - 94% PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 2 PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 2 - 73% PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 2 - 87% PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 2 - 94% PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 6 PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 6 - 73% PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 6 - 87% PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 6 - 94% PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan AH1 (0-20% FPL) Individual Policy Schedule of Benefits 1/1/2022
Silver Plan AH1 (21 - 40% FPL) Individual Policy Schedule of Benefits 1/1/2022
Silver Plan AH1 (41 - 60% FPL) Individual Policy Schedule of Benefits 1/1/2022
Silver Plan AH1 (61 - 80% FPL) Individual Policy Schedule of Benefits 1/1/2022
Silver Plan AH1 (81 - 100% FPL) Individual Policy Schedule of Benefits 1/1/2022
Silver Plan AH1 (101 - 120% FPL) Individual Policy Schedule of Benefits 1/1/2022
Silver Plan AH1 (121 - 138% FPL) Individual Policy Schedule of Benefits 1/1/2022

Bronze 2022

PlanIndividual Policy Schedule of Benefits Effective Date
Bronze Plan 1 PPO Individual Policy Schedule of Benefits 1/1/2022
Bronze Plan HSA 1 Individual Policy Schedule of Benefits 1/1/2022
Bronze Plan 3 PPO Individual Policy Schedule of Benefits 1/1/2022

Gold 2022

PlanIndividual PolicySchedule of BenefitsEffective Date
Gold Plan HSA1 Individual Policy Schedule of Benefits 1/1/2022

AMERICAN INDIAN / ALASKAN NATIVE

Silver 2022

PlanIndividual PolicySchedule of BenefitsEffective Date
Silver Plan AH1 - Indian Under 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan AH1 - Indian Over 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 1 - Indian Under 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 1 - Indian Over 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan H1 - Indian Under 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan H1 - Indian Over 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 2 - Indian Under 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 2 - Indian Over 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 6 - Indian Under 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 6 - Indian Over 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022

Bronze 2022

PlanIndividual PolicySchedule of BenefitsEffective Date
Bronze Plan 1 - Indian Under 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022
Bronze Plan 1 - Indian Over 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022
Bronze Plan H1 - Indian Under 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022
Bronze Plan H1 - Indian Over 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022
Bronze Plan 3 - Indian Under 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022
Bronze Plan 3 - Indian Over 300% FPL PPO Individual Policy Schedule of Benefits 1/1/2022

Gold 2022

PlanIndividual PolicySchedule of BenefitsEffective Date
Gold Plan H1 - Indian Under 300% FPL Individual Policy Schedule of Benefits 1/1/2022
Gold Plan H1 - Indian Over 300% FPL Individual Policy Schedule of Benefits 1/1/2022

OFF-EXCHANGE

Silver 2022

PlanIndividual PolicySchedule of BenefitsEffective Date
Silver Plan AH1 (monthly) Individual Policy Schedule of Benefits 1/1/2022
Silver Plan AH1 (quarterly) Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 1 (monthly) Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 1 (quarterly) Individual Policy Schedule of Benefits 1/1/2022
Silver Plan HSA 1 (monthly) Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 2 (monthly) Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 2 (quarterly) Individual Policy Schedule of Benefits 1/1/2022
Silver Plan 6 (monthly) Individual Policy Schedule of Benefits 1/1/2022

Bronze 2022

PlanIndividual PolicySchedule of BenefitsEffective Date
Bronze Plan 1 (monthly) Individual Policy Schedule of Benefits 1/1/2022
Bronze Plan 1 (quarterly) Individual Policy Schedule of Benefits 1/1/2022
Bronze Plan HSA1 (monthly) Individual Policy Schedule of Benefits 1/1/2022
Bronze Plan HSA1 (quarterly) Individual Policy Schedule of Benefits 1/1/2022
Bronze Plan 3 (monthly) Individual Policy Schedule of Benefits 1/1/2022

Gold 2022

PlanIndividual PolicySchedule of BenefitsEffective Date
Gold Plan HSA1 (monthly) Individual Policy Schedule of Benefits 1/1/2022

*CSR-Cost sharing reduction: A discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance, and copayments. You can get this reduction if you get health insurance through the Marketplace, your income is below a certain level and you choose a health plan from the Silver plan category. If you are a member of a federally recognized tribe, you may qualify for additional cost-sharing benefits.

Note: Policy ID may also be referenced as Certificate ID in other correspondence.