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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 2021 plan year

ON-EXCHANGE

Silver 2021

Plan Individual Policy Schedule of Benefits Effective Date
Silver Plan AW 1 Individual Policy Schedule of Benefits 1/1/2021
Silver Plan AW1 73% CSR 2500 deductible Individual Policy Schedule of Benefits 1/1/2021
Silver Plan AW1 87% CSR 1200 deductible Individual Policy Schedule of Benefits 1/1/2021
Silver Plan AW1 94% CSR 1200 deductible Individual Policy Schedule of Benefits 1/1/2021
Silver Plan AW1 PO Plan Under 100% FPL 0 deductible Individual Policy Schedule of Benefits 1/1/2021
Silver Plan AW1 PO Plan Under 100 - 138% FPL 0 deductible Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 1 Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 1 73% CSR 2750 deductible Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 1 87% CSR 1125 deductible Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 1 94% CSR 400 deductible Individual Policy Schedule of Benefits 1/1/2021
Silver Plan HSA1 Individual Policy Schedule of Benefits 1/1/2021
Silver Plan HSA1 73% CSR 2800 deductible Individual Policy Schedule of Benefits 1/1/2021
Silver Plan HSA1 87% CSR 1700 deductible Individual Policy Schedule of Benefits 1/1/2021
Silver Plan HSA1 94% CSR 625 deductible Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 2 Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 2 73% CSR 4000 deductible Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 2 87% CSR 1600 deductible Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 2 94% CSR 400 deductible Individual Policy Schedule of Benefits 1/1/2021

Bronze 2021

PlanIndividual Policy Schedule of Benefits Effective Date
Bronze Plan 1 Individual Policy Schedule of Benefits 1/1/2021
Bronze Plan HSA1 Individual Policy Schedule of Benefits 1/1/2021

Gold 2021

PlanIndividual PolicySchedule of BenefitsEffective Date
Gold Plan HSA1 Individual Policy Schedule of Benefits 1/1/2021

AMERICAN INDIAN / ALASKAN NATIVE

Silver 2021

PlanIndividual PolicySchedule of BenefitsEffective Date
Silver Plan AW1 Indian < 300% Individual Policy Schedule of Benefits 1/1/2021
Silver Plan AW1 Indian > 300% Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 1 Indian < 300% Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 1 Indian > 300% Individual Policy Schedule of Benefits 1/1/2021
Silver Plan Indian < 300% Individual Policy Schedule of Benefits 1/1/2021
Silver Plan HSA1 Indian > 300% Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 2 Indian <300% Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 2 Indian >300% Individual Policy Schedule of Benefits 1/1/2021

Bronze 2021

PlanIndividual PolicySchedule of BenefitsEffective Date
Bronze Plan 1 Indian < 300% Individual Policy Schedule of Benefits 1/1/2021
Bronze Plan 1 Indian > 300% Individual Policy Schedule of Benefits 1/1/2021
Bronze Plan HSA 1 Indian < 300% Individual Policy Schedule of Benefits 1/1/2021
Bronze Plan HSA 1 Indian > 300% Individual Policy Schedule of Benefits 1/1/2021

Gold 2021

PlanIndividual PolicySchedule of BenefitsEffective Date
Gold Plan Indian < 300% Individual Policy Schedule of Benefits 1/1/2021
Gold Plan HSA1 Indian > 300% Individual Policy Schedule of Benefits 1/1/2021

OFF-EXCHANGE

Silver 2021

PlanIndividual PolicySchedule of BenefitsEffective Date
Silver Plan AW1 (monthly billing) Individual Policy Schedule of Benefits 1/1/2021
Silver Plan AW1 (quarterly billing) Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 1 (monthly billing) Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 1 (quarterly billing) Individual Policy Schedule of Benefits 1/1/2021
Silver Plan HSA1 Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 2 (monthly billing) Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 2 (quarterly billing) Individual Policy Schedule of Benefits 1/1/2021
Silver Plan 3 Individual Policy Schedule of Benefits 1/1/2021

Bronze 2021

PlanIndividual PolicySchedule of BenefitsEffective Date
Bronze Plan 1 (monthly billing) Individual Policy Schedule of Benefits 1/1/2021
Bronze Plan 1 (quarterly billing) Individual Policy Schedule of Benefits 1/1/2021
Bronze Plan HSA1 (monthly billing) Individual Policy Schedule of Benefits 1/1/2021
Bronze Plan HSA1 (quarterly billing) Individual Policy Schedule of Benefits 1/1/2021
Bronze Plan 2 Individual Policy Schedule of Benefits 1/1/2021

Gold 2021

PlanIndividual PolicySchedule of BenefitsEffective Date
Gold Plan 1 Individual Policy Schedule of Benefits 1/1/2021
Gold Plan HSA1 Individual Policy Schedule of Benefits 1/1/2021

*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.