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Providers for Zip Code 22046

LegalConsumer.com/obamacare

ObamacareByZipCode.com

Obamacare 2016 Marketplace Rates For Loudoun County, Virginia

Friday, April 19th, 2024


The health insurance rates listed below are for calendar year 2016.

2016 Rates and Providers

(click here for 2014)

(click here for 2015)

This page gives you an overview of the rates for individual and family health insurance plans available from HealthCare.gov, the marketplace for Loudoun County, Virginia.

Obamacare Providers, Plans and 2016 Rates for Loudoun County

Loudoun County is in “Rating Area 10” of Virginia.

Currently, there are 6 providers offering 63 plans to Rating Area 10. †

Below, you’ll find a summary of plans and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options. For detailed information on available subsidies to make your coverage affordable, you must complete an application at HealthCare.gov or contact the provider directly.

The table below shows premiums for the following scenarios for:

  • Individual
  • Couple
  • Couple with 1 2 or 3 children
  • Individual with 1 2 or 3 children
  • A child alone

Each scenario is covered for age

  • Age 21, 30, 40, 50
  • Age 60 (Individual and Couple only)

For each plan, there are links that go to the insurance provider's website in a new window. You can find links to:

  • a summary of plan benefits and costs,
  • a plan brochure, and
  • a "Provider Directory" -- where you can find out which doctors and hospitals in the Falls Church, VA area accept this insurance coverage as within the plan's "network".
ADVERTISEMENT

CareFirst BlueChoice, Inc.

Local: 1-855-444-3119 | Toll Free: 1-855-444-3119

TTY: 1-202-479-3546

Plan: (HMO) BlueChoice HMO Silver $2,000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $307.90
$349.47
$393.50
$549.91
$835.64		 $615.80
$698.94
$787.00
$1099.82
$1671.28		 $811.32
$894.46
$982.52
$1295.34		 $1006.84
$1089.98
$1178.04
$1490.86		 $1202.36
$1285.50
$1373.56
$1686.38		 $503.42
$544.99
$589.02
$745.43		 $698.94
$740.51
$784.54
$940.95		 $894.46
$936.03
$980.06
$1136.47		 $195.52

Plan: (HMO) HealthyBlue HMO Gold $250

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

Deductible: Individual: $250 : Family: $500
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $366.76
$416.27
$468.72
$655.03
$995.39		 $733.52
$832.54
$937.44
$1310.06
$1990.78		 $966.41
$1065.43
$1170.33
$1542.95		 $1199.30
$1298.32
$1403.22
$1775.84		 $1432.19
$1531.21
$1636.11
$2008.73		 $599.65
$649.16
$701.61
$887.92		 $832.54
$882.05
$934.50
$1120.81		 $1065.43
$1114.94
$1167.39
$1353.70		 $232.89

Plan: (HMO) HealthyBlue HMO Gold $1,000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $4,500 : Family: $9,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $355.35
$403.32
$454.14
$634.66
$964.42		 $710.70
$806.64
$908.28
$1269.32
$1928.84		 $936.35
$1032.29
$1133.93
$1494.97		 $1162.00
$1257.94
$1359.58
$1720.62		 $1387.65
$1483.59
$1585.23
$1946.27		 $581.00
$628.97
$679.79
$860.31		 $806.65
$854.62
$905.44
$1085.96		 $1032.30
$1080.27
$1131.09
$1311.61		 $225.65

Plan: (HMO) BlueChoice HMO Young Adult $6,850

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

Deductible: Individual: $6,850 : Family: $13,700
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Catastrophic 21
30
40
50
60		 $154.70
$175.58
$197.71
$276.29
$419.86		 $309.40
$351.16
$395.42
$552.58
$839.72		 $407.63
$449.39
$493.65
$650.81		 $505.86
$547.62
$591.88
$749.04		 $604.09
$645.85
$690.11
$847.27		 $252.93
$273.81
$295.94
$374.52		 $351.16
$372.04
$394.17
$472.75		 $449.39
$470.27
$492.40
$570.98		 $98.23

Plan: (HMO) BlueChoice HMO HSA Bronze $6,000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $173.29
$196.68
$221.46
$309.50
$470.31		 $346.58
$393.36
$442.92
$619.00
$940.62		 $456.62
$503.40
$552.96
$729.04		 $566.66
$613.44
$663.00
$839.08		 $676.70
$723.48
$773.04
$949.12		 $283.33
$306.72
$331.50
$419.54		 $393.37
$416.76
$441.54
$529.58		 $503.41
$526.80
$551.58
$639.62		 $110.04

Plan: (HMO) BlueChoice HMO HSA Silver $1,350

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

Deductible: Individual: $1,350 : Family: $2,700
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $278.59
$316.20
$356.04
$497.56
$756.09		 $557.18
$632.40
$712.08
$995.12
$1512.18		 $734.08
$809.30
$888.98
$1172.02		 $910.98
$986.20
$1065.88
$1348.92		 $1087.88
$1163.10
$1242.78
$1525.82		 $455.49
$493.10
$532.94
$674.46		 $632.39
$670.00
$709.84
$851.36		 $809.29
$846.90
$886.74
$1028.26		 $176.90

Plan: (HMO) BlueChoice HMO HSA Bronze $6,550

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $168.39
$191.12
$215.20
$300.74
$457.01		 $336.78
$382.24
$430.40
$601.48
$914.02		 $443.71
$489.17
$537.33
$708.41		 $550.64
$596.10
$644.26
$815.34		 $657.57
$703.03
$751.19
$922.27		 $275.32
$298.05
$322.13
$407.67		 $382.25
$404.98
$429.06
$514.60		 $489.18
$511.91
$535.99
$621.53		 $106.93

Plan: (POS) BlueChoice Plus Bronze $5,500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $225.42
$255.85
$288.09
$402.60
$611.79		 $450.84
$511.70
$576.18
$805.20
$1223.58		 $593.98
$654.84
$719.32
$948.34		 $737.12
$797.98
$862.46
$1091.48		 $880.26
$941.12
$1005.60
$1234.62		 $368.56
$398.99
$431.23
$545.74		 $511.70
$542.13
$574.37
$688.88		 $654.84
$685.27
$717.51
$832.02		 $143.14

Plan: (POS) BlueChoice Plus Silver $2,500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $307.98
$349.56
$393.60
$550.05
$835.86		 $615.96
$699.12
$787.20
$1100.10
$1671.72		 $811.53
$894.69
$982.77
$1295.67		 $1007.10
$1090.26
$1178.34
$1491.24		 $1202.67
$1285.83
$1373.91
$1686.81		 $503.55
$545.13
$589.17
$745.62		 $699.12
$740.70
$784.74
$941.19		 $894.69
$936.27
$980.31
$1136.76		 $195.57

Plan: (POS) HealthyBlue Plus Gold $750

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (CareFirst BlueChoice, Inc.)

Deductible: Individual: $750 : Family: $1,500
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $373.86
$424.33
$477.79
$667.71
$1014.66		 $747.72
$848.66
$955.58
$1335.42
$2029.32		 $985.12
$1086.06
$1192.98
$1572.82		 $1222.52
$1323.46
$1430.38
$1810.22		 $1459.92
$1560.86
$1667.78
$2047.62		 $611.26
$661.73
$715.19
$905.11		 $848.66
$899.13
$952.59
$1142.51		 $1086.06
$1136.53
$1189.99
$1379.91		 $237.40
ADVERTISEMENT

Innovation Health Insurance Company

Local: 1-866-833-2957 | Toll Free: 1-866-833-2957

TTY: 1-866-833-2957

Plan: (PPO) Innovation Health Leap Bronze Plus

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $6,850 : Family: $13,700
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $168.05
$190.73
$214.76
$300.13
$456.08		 $336.10
$381.46
$429.52
$600.26
$912.16		 $442.81
$488.17
$536.23
$706.97		 $549.52
$594.88
$642.94
$813.68		 $656.23
$701.59
$749.65
$920.39		 $274.76
$297.44
$321.47
$406.84		 $381.47
$404.15
$428.18
$513.55		 $488.18
$510.86
$534.89
$620.26		 $106.71

Plan: (PPO) Innovation Health Leap Catastrophic

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $6,850 : Family: $13,700
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Catastrophic 21
30
40
50
60		 $139.79
$158.66
$178.65
$249.66
$379.39		 $279.58
$317.32
$357.30
$499.32
$758.78		 $368.35
$406.09
$446.07
$588.09		 $457.12
$494.86
$534.84
$676.86		 $545.89
$583.63
$623.61
$765.63		 $228.56
$247.43
$267.42
$338.43		 $317.33
$336.20
$356.19
$427.20		 $406.10
$424.97
$444.96
$515.97		 $88.77

Plan: (PPO) Innovation Health Leap Silver Basic

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $5,250 : Family: $10,500
Out of Pocket Maximum per year: Individual: $5,250 : Family: $10,500

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $211.63
$240.20
$270.47
$377.98
$574.37		 $423.26
$480.40
$540.94
$755.96
$1148.74		 $557.65
$614.79
$675.33
$890.35		 $692.04
$749.18
$809.72
$1024.74		 $826.43
$883.57
$944.11
$1159.13		 $346.02
$374.59
$404.86
$512.37		 $480.41
$508.98
$539.25
$646.76		 $614.80
$643.37
$673.64
$781.15		 $134.39

Plan: (PPO) Innovation Health Leap Bronze HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $6,450 : Family: $12,900
Out of Pocket Maximum per year: Individual: $6,450 : Family: $12,900

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $166.51
$188.99
$212.80
$297.39
$451.91		 $333.02
$377.98
$425.60
$594.78
$903.82		 $438.75
$483.71
$531.33
$700.51		 $544.48
$589.44
$637.06
$806.24		 $650.21
$695.17
$742.79
$911.97		 $272.24
$294.72
$318.53
$403.12		 $377.97
$400.45
$424.26
$508.85		 $483.70
$506.18
$529.99
$614.58		 $105.73

Plan: (PPO) Innovation Health Leap Gold Basic

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $298.47
$338.76
$381.44
$533.06
$810.04		 $596.94
$677.52
$762.88
$1066.12
$1620.08		 $786.47
$867.05
$952.41
$1255.65		 $976.00
$1056.58
$1141.94
$1445.18		 $1165.53
$1246.11
$1331.47
$1634.71		 $488.00
$528.29
$570.97
$722.59		 $677.53
$717.82
$760.50
$912.12		 $867.06
$907.35
$950.03
$1101.65		 $189.53

Plan: (PPO) Innovation Health Leap Silver Plus

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $4,510 : Family: $9,020
Out of Pocket Maximum per year: Individual: $4,510 : Family: $9,020

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $227.33
$258.02
$290.53
$406.01
$616.97		 $454.66
$516.04
$581.06
$812.02
$1233.94		 $599.01
$660.39
$725.41
$956.37		 $743.36
$804.74
$869.76
$1100.72		 $887.71
$949.09
$1014.11
$1245.07		 $371.68
$402.37
$434.88
$550.36		 $516.03
$546.72
$579.23
$694.71		 $660.38
$691.07
$723.58
$839.06		 $144.35

Plan: (PPO) Innovation Health Leap Bronze Basic

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $6,850 : Family: $13,700
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $162.03
$183.90
$207.07
$289.38
$439.74		 $324.06
$367.80
$414.14
$578.76
$879.48		 $426.95
$470.69
$517.03
$681.65		 $529.84
$573.58
$619.92
$784.54		 $632.73
$676.47
$722.81
$887.43		 $264.92
$286.79
$309.96
$392.27		 $367.81
$389.68
$412.85
$495.16		 $470.70
$492.57
$515.74
$598.05		 $102.89

Plan: (PPO) Innovation Health Leap Gold Diabetes

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-866-833-2957 - Provider Directory for This Plan: (Innovation Health Insurance Company)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $310.29
$352.18
$396.55
$554.18
$842.14		 $620.58
$704.36
$793.10
$1108.36
$1684.28		 $817.62
$901.40
$990.14
$1305.40		 $1014.66
$1098.44
$1187.18
$1502.44		 $1211.70
$1295.48
$1384.22
$1699.48		 $507.33
$549.22
$593.59
$751.22		 $704.37
$746.26
$790.63
$948.26		 $901.41
$943.30
$987.67
$1145.30		 $197.04
ADVERTISEMENT

UnitedHealthcare of the Mid-Atlantic Inc

Local: 1-877-632-4195 | Toll Free: 1-877-632-4195

Plan: (HMO) Gold Compass 0-1

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-632-4195 - Provider Directory for This Plan: (UnitedHealthcare of the Mid-Atlantic Inc)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $272.11
$308.83
$347.75
$485.97
$738.48		 $544.22
$617.66
$695.50
$971.94
$1476.96		 $717.00
$790.44
$868.28
$1144.72		 $889.78
$963.22
$1041.06
$1317.50		 $1062.56
$1136.00
$1213.84
$1490.28		 $444.89
$481.61
$520.53
$658.75		 $617.67
$654.39
$693.31
$831.53		 $790.45
$827.17
$866.09
$1004.31		 $172.78

Plan: (HMO) Gold Compass 1000-1

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-632-4195 - Provider Directory for This Plan: (UnitedHealthcare of the Mid-Atlantic Inc)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $276.98
$314.36
$353.96
$494.66
$751.68		 $553.96
$628.72
$707.92
$989.32
$1503.36		 $729.83
$804.59
$883.79
$1165.19		 $905.70
$980.46
$1059.66
$1341.06		 $1081.57
$1156.33
$1235.53
$1516.93		 $452.85
$490.23
$529.83
$670.53		 $628.72
$666.10
$705.70
$846.40		 $804.59
$841.97
$881.57
$1022.27		 $175.87

Plan: (HMO) Silver Compass HSA 2000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-632-4195 - Provider Directory for This Plan: (UnitedHealthcare of the Mid-Atlantic Inc)

Deductible: Individual: $2,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $6,850

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $225.73
$256.20
$288.48
$403.14
$612.61		 $451.46
$512.40
$576.96
$806.28
$1225.22		 $594.79
$655.73
$720.29
$949.61		 $738.12
$799.06
$863.62
$1092.94		 $881.45
$942.39
$1006.95
$1236.27		 $369.06
$399.53
$431.81
$546.47		 $512.39
$542.86
$575.14
$689.80		 $655.72
$686.19
$718.47
$833.13		 $143.33

Plan: (HMO) Silver Compass 4500-1

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-632-4195 - Provider Directory for This Plan: (UnitedHealthcare of the Mid-Atlantic Inc)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $236.11
$267.98
$301.74
$421.68
$640.78		 $472.22
$535.96
$603.48
$843.36
$1281.56		 $622.14
$685.88
$753.40
$993.28		 $772.06
$835.80
$903.32
$1143.20		 $921.98
$985.72
$1053.24
$1293.12		 $386.03
$417.90
$451.66
$571.60		 $535.95
$567.82
$601.58
$721.52		 $685.87
$717.74
$751.50
$871.44		 $149.92

Plan: (HMO) Bronze Compass HSA 5500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-632-4195 - Provider Directory for This Plan: (UnitedHealthcare of the Mid-Atlantic Inc)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $190.71
$216.44
$243.71
$340.59
$517.55		 $381.42
$432.88
$487.42
$681.18
$1035.10		 $502.51
$553.97
$608.51
$802.27		 $623.60
$675.06
$729.60
$923.36		 $744.69
$796.15
$850.69
$1044.45		 $311.80
$337.53
$364.80
$461.68		 $432.89
$458.62
$485.89
$582.77		 $553.98
$579.71
$606.98
$703.86		 $121.09

Plan: (HMO) Bronze Compass 6500-1

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-632-4195 - Provider Directory for This Plan: (UnitedHealthcare of the Mid-Atlantic Inc)

Deductible: Individual: $6,500 : Family: $13,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $205.95
$233.74
$263.19
$367.81
$558.92		 $411.90
$467.48
$526.38
$735.62
$1117.84		 $542.67
$598.25
$657.15
$866.39		 $673.44
$729.02
$787.92
$997.16		 $804.21
$859.79
$918.69
$1127.93		 $336.72
$364.51
$393.96
$498.58		 $467.49
$495.28
$524.73
$629.35		 $598.26
$626.05
$655.50
$760.12		 $130.77
ADVERTISEMENT

Group Hospitalization and Medical Services Inc.

Local: 1-855-444-3119 | Toll Free: 1-855-444-3119

TTY: 1-202-479-3546

Plan: (PPO) BlueCross BlueShield Preferred 500, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (Group Hospitalization and Medical Services Inc.)

Deductible: Individual: $500 : Family: $1,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $435.29
$494.05
$556.30
$777.43
$1181.38		 $870.58
$988.10
$1112.60
$1554.86
$2362.76		 $1146.99
$1264.51
$1389.01
$1831.27		 $1423.40
$1540.92
$1665.42
$2107.68		 $1699.81
$1817.33
$1941.83
$2384.09		 $711.70
$770.46
$832.71
$1053.84		 $988.11
$1046.87
$1109.12
$1330.25		 $1264.52
$1323.28
$1385.53
$1606.66		 $276.41

Plan: (PPO) BlueCross BlueShield Preferred 1600, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (Group Hospitalization and Medical Services Inc.)

Deductible: Individual: $1,600 : Family: $3,200
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $322.75
$366.32
$412.47
$576.43
$875.94		 $645.50
$732.64
$824.94
$1152.86
$1751.88		 $850.45
$937.59
$1029.89
$1357.81		 $1055.40
$1142.54
$1234.84
$1562.76		 $1260.35
$1347.49
$1439.79
$1767.71		 $527.70
$571.27
$617.42
$781.38		 $732.65
$776.22
$822.37
$986.33		 $937.60
$981.17
$1027.32
$1191.28		 $204.95

Plan: (PPO) BluePreferred PPO HSA Bronze $4,500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-444-3119 - Provider Directory for This Plan: (Group Hospitalization and Medical Services Inc.)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $223.02
$253.13
$285.02
$398.31
$605.28		 $446.04
$506.26
$570.04
$796.62
$1210.56		 $587.66
$647.88
$711.66
$938.24		 $729.28
$789.50
$853.28
$1079.86		 $870.90
$931.12
$994.90
$1221.48		 $364.64
$394.75
$426.64
$539.93		 $506.26
$536.37
$568.26
$681.55		 $647.88
$677.99
$709.88
$823.17		 $141.62
ADVERTISEMENT

HealthKeepers, Inc.

Local: 1-855-748-1810 | Toll Free: 1-855-748-1810

Plan: (HMO) Anthem HealthKeepers Catastrophic X 6850 0

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $6,850 : Family: $13,700
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Catastrophic 21
30
40
50
60		 $171.87
$195.07
$219.65
$306.96
$466.46		 $343.74
$390.14
$439.30
$613.92
$932.92		 $452.88
$499.28
$548.44
$723.06		 $562.02
$608.42
$657.58
$832.20		 $671.16
$717.56
$766.72
$941.34		 $281.01
$304.21
$328.79
$416.10		 $390.15
$413.35
$437.93
$525.24		 $499.29
$522.49
$547.07
$634.38		 $109.14

Plan: (HMO) Anthem HealthKeepers Bronze X 15 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $213.44
$242.25
$272.78
$381.20
$579.28		 $426.88
$484.50
$545.56
$762.40
$1158.56		 $562.41
$620.03
$681.09
$897.93		 $697.94
$755.56
$816.62
$1033.46		 $833.47
$891.09
$952.15
$1168.99		 $348.97
$377.78
$408.31
$516.73		 $484.50
$513.31
$543.84
$652.26		 $620.03
$648.84
$679.37
$787.79		 $135.53

Plan: (HMO) Anthem HealthKeepers Bronze X 5500 25

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $210.09
$238.45
$268.50
$375.22
$570.18		 $420.18
$476.90
$537.00
$750.44
$1140.36		 $553.59
$610.31
$670.41
$883.85		 $687.00
$743.72
$803.82
$1017.26		 $820.41
$877.13
$937.23
$1150.67		 $343.50
$371.86
$401.91
$508.63		 $476.91
$505.27
$535.32
$642.04		 $610.32
$638.68
$668.73
$775.45		 $133.41

Plan: (HMO) Anthem HealthKeepers Bronze X 4650 35

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $4,650 : Family: $9,300
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $212.21
$240.86
$271.20
$379.01
$575.94		 $424.42
$481.72
$542.40
$758.02
$1151.88		 $559.17
$616.47
$677.15
$892.77		 $693.92
$751.22
$811.90
$1027.52		 $828.67
$885.97
$946.65
$1162.27		 $346.96
$375.61
$405.95
$513.76		 $481.71
$510.36
$540.70
$648.51		 $616.46
$645.11
$675.45
$783.26		 $134.75

Plan: (HMO) Anthem HealthKeepers Bronze X 35 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $220.57
$250.35
$281.89
$393.94
$598.63		 $441.14
$500.70
$563.78
$787.88
$1197.26		 $581.20
$640.76
$703.84
$927.94		 $721.26
$780.82
$843.90
$1068.00		 $861.32
$920.88
$983.96
$1208.06		 $360.63
$390.41
$421.95
$534.00		 $500.69
$530.47
$562.01
$674.06		 $640.75
$670.53
$702.07
$814.12		 $140.06

Plan: (HMO) Anthem HealthKeepers Silver X 3350 15

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $3,350 : Family: $6,700
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $236.81
$268.78
$302.64
$422.94
$642.70		 $473.62
$537.56
$605.28
$845.88
$1285.40		 $623.99
$687.93
$755.65
$996.25		 $774.36
$838.30
$906.02
$1146.62		 $924.73
$988.67
$1056.39
$1296.99		 $387.18
$419.15
$453.01
$573.31		 $537.55
$569.52
$603.38
$723.68		 $687.92
$719.89
$753.75
$874.05		 $150.37

Plan: (HMO) Anthem HealthKeepers Silver X 2600 20

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $2,600 : Family: $5,200
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $242.86
$275.65
$310.38
$433.75
$659.12		 $485.72
$551.30
$620.76
$867.50
$1318.24		 $639.94
$705.52
$774.98
$1021.72		 $794.16
$859.74
$929.20
$1175.94		 $948.38
$1013.96
$1083.42
$1330.16		 $397.08
$429.87
$464.60
$587.97		 $551.30
$584.09
$618.82
$742.19		 $705.52
$738.31
$773.04
$896.41		 $154.22

Plan: (HMO) Anthem HealthKeepers Silver X 2250 20

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $2,250 : Family: $4,500
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $248.40
$281.93
$317.46
$443.64
$674.16		 $496.80
$563.86
$634.92
$887.28
$1348.32		 $654.53
$721.59
$792.65
$1045.01		 $812.26
$879.32
$950.38
$1202.74		 $969.99
$1037.05
$1108.11
$1360.47		 $406.13
$439.66
$475.19
$601.37		 $563.86
$597.39
$632.92
$759.10		 $721.59
$755.12
$790.65
$916.83		 $157.73

Plan: (HMO) Anthem HealthKeepers Bronze X 50 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $6,100 : Family: $12,200
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $205.67
$233.44
$262.85
$367.33
$558.19		 $411.34
$466.88
$525.70
$734.66
$1116.38		 $541.94
$597.48
$656.30
$865.26		 $672.54
$728.08
$786.90
$995.86		 $803.14
$858.68
$917.50
$1126.46		 $336.27
$364.04
$393.45
$497.93		 $466.87
$494.64
$524.05
$628.53		 $597.47
$625.24
$654.65
$759.13		 $130.60

Plan: (HMO) Anthem HealthKeepers Silver, a Blue Cross and Blue Shield Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $1,550 : Family: $3,100
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $252.64
$286.75
$322.87
$451.22
$685.66		 $505.28
$573.50
$645.74
$902.44
$1371.32		 $665.71
$733.93
$806.17
$1062.87		 $826.14
$894.36
$966.60
$1223.30		 $986.57
$1054.79
$1127.03
$1383.73		 $413.07
$447.18
$483.30
$611.65		 $573.50
$607.61
$643.73
$772.08		 $733.93
$768.04
$804.16
$932.51		 $160.43

Plan: (HMO) Anthem HealthKeepers Gold, a Blue Cross and Blue Shield Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $750 : Family: $1,500
Out of Pocket Maximum per year: Individual: $5,200 : Family: $10,400

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $313.29
$355.58
$400.38
$559.54
$850.27		 $626.58
$711.16
$800.76
$1119.08
$1700.54		 $825.52
$910.10
$999.70
$1318.02		 $1024.46
$1109.04
$1198.64
$1516.96		 $1223.40
$1307.98
$1397.58
$1715.90		 $512.23
$554.52
$599.32
$758.48		 $711.17
$753.46
$798.26
$957.42		 $910.11
$952.40
$997.20
$1156.36		 $198.94

Plan: (POS) Anthem HealthKeepers Bronze X POS 4100 30

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $4,100 : Family: $8,200
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $228.63
$259.50
$292.19
$408.33
$620.50		 $457.26
$519.00
$584.38
$816.66
$1241.00		 $602.44
$664.18
$729.56
$961.84		 $747.62
$809.36
$874.74
$1107.02		 $892.80
$954.54
$1019.92
$1252.20		 $373.81
$404.68
$437.37
$553.51		 $518.99
$549.86
$582.55
$698.69		 $664.17
$695.04
$727.73
$843.87		 $145.18

Plan: (POS) Anthem HealthKeepers Silver X POS 2000 20

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $257.51
$292.27
$329.10
$459.91
$698.88		 $515.02
$584.54
$658.20
$919.82
$1397.76		 $678.54
$748.06
$821.72
$1083.34		 $842.06
$911.58
$985.24
$1246.86		 $1005.58
$1075.10
$1148.76
$1410.38		 $421.03
$455.79
$492.62
$623.43		 $584.55
$619.31
$656.14
$786.95		 $748.07
$782.83
$819.66
$950.47		 $163.52

Plan: (POS) Anthem HealthKeepers Gold X POS 1100 15

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $1,100 : Family: $2,200
Out of Pocket Maximum per year: Individual: $4,800 : Family: $9,600

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $319.08
$362.16
$407.78
$569.88
$865.98		 $638.16
$724.32
$815.56
$1139.76
$1731.96		 $840.78
$926.94
$1018.18
$1342.38		 $1043.40
$1129.56
$1220.80
$1545.00		 $1246.02
$1332.18
$1423.42
$1747.62		 $521.70
$564.78
$610.40
$772.50		 $724.32
$767.40
$813.02
$975.12		 $926.94
$970.02
$1015.64
$1177.74		 $202.62

Plan: (POS) Anthem HealthKeepers Bronze POS X 0 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1810 - Provider Directory for This Plan: (HealthKeepers, Inc.)

Deductible: Individual: $5,350 : Family: $10,700
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $229.07
$259.99
$292.75
$409.12
$621.70		 $458.14
$519.98
$585.50
$818.24
$1243.40		 $603.60
$665.44
$730.96
$963.70		 $749.06
$810.90
$876.42
$1109.16		 $894.52
$956.36
$1021.88
$1254.62		 $374.53
$405.45
$438.21
$554.58		 $519.99
$550.91
$583.67
$700.04		 $665.45
$696.37
$729.13
$845.50		 $145.46
ADVERTISEMENT

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

Local: 1-800-807-1140 | Toll Free: 1-800-807-1140

TTY: 1-703-359-7616

Plan: (HMO) KP VA Gold 0/20/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $303.77
$344.76
$388.02
$542.41
$823.86		 $607.54
$689.52
$776.04
$1084.82
$1647.72		 $800.18
$882.16
$968.68
$1277.46		 $992.82
$1074.80
$1161.32
$1470.10		 $1185.46
$1267.44
$1353.96
$1662.74		 $496.41
$537.40
$580.66
$735.05		 $689.05
$730.04
$773.30
$927.69		 $881.69
$922.68
$965.94
$1120.33		 $192.64

Plan: (HMO) KP VA Gold 1000/20/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Gold 21
30
40
50
60		 $283.01
$321.20
$361.51
$505.35
$767.57		 $566.02
$642.40
$723.02
$1010.70
$1535.14		 $745.50
$821.88
$902.50
$1190.18		 $924.98
$1001.36
$1081.98
$1369.66		 $1104.46
$1180.84
$1261.46
$1549.14		 $462.49
$500.68
$540.99
$684.83		 $641.97
$680.16
$720.47
$864.31		 $821.45
$859.64
$899.95
$1043.79		 $179.48

Plan: (HMO) KP VA Silver 1500/30/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $246.44
$279.70
$314.80
$440.05
$668.39		 $492.88
$559.40
$629.60
$880.10
$1336.78		 $649.17
$715.69
$785.89
$1036.39		 $805.46
$871.98
$942.18
$1192.68		 $961.75
$1028.27
$1098.47
$1348.97		 $402.73
$435.99
$471.09
$596.34		 $559.02
$592.28
$627.38
$752.63		 $715.31
$748.57
$783.67
$908.92		 $156.29

Plan: (HMO) KP VA Silver 2500/30/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $234.25
$265.86
$299.23
$418.28
$635.33		 $468.50
$531.72
$598.46
$836.56
$1270.66		 $617.06
$680.28
$747.02
$985.12		 $765.62
$828.84
$895.58
$1133.68		 $914.18
$977.40
$1044.14
$1282.24		 $382.81
$414.42
$447.79
$566.84		 $531.37
$562.98
$596.35
$715.40		 $679.93
$711.54
$744.91
$863.96		 $148.56

Plan: (HMO) KP VA Silver 2750/20%/HSA/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $2,750 : Family: $5,500
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Silver 21
30
40
50
60		 $222.06
$252.03
$283.65
$396.51
$602.26		 $444.12
$504.06
$567.30
$793.02
$1204.52		 $584.95
$644.89
$708.13
$933.85		 $725.78
$785.72
$848.96
$1074.68		 $866.61
$926.55
$989.79
$1215.51		 $362.89
$392.86
$424.48
$537.34		 $503.72
$533.69
$565.31
$678.17		 $644.55
$674.52
$706.14
$819.00		 $140.83

Plan: (HMO) KP VA Bronze 4500/50/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $195.70
$222.11
$249.98
$349.44
$530.77		 $391.40
$444.22
$499.96
$698.88
$1061.54		 $515.51
$568.33
$624.07
$822.99		 $639.62
$692.44
$748.18
$947.10		 $763.73
$816.55
$872.29
$1071.21		 $319.81
$346.22
$374.09
$473.55		 $443.92
$470.33
$498.20
$597.66		 $568.03
$594.44
$622.31
$721.77		 $124.11

Plan: (HMO) KP VA Bronze 5000/50/HSA/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,450 : Family: $12,900

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $187.47
$212.76
$239.46
$334.74
$508.44		 $374.94
$425.52
$478.92
$669.48
$1016.88		 $493.83
$544.41
$597.81
$788.37		 $612.72
$663.30
$716.70
$907.26		 $731.61
$782.19
$835.59
$1026.15		 $306.36
$331.65
$358.35
$453.63		 $425.25
$450.54
$477.24
$572.52		 $544.14
$569.43
$596.13
$691.41		 $118.89

Plan: (HMO) KP VA Bronze 6000/20%/HSA/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,450 : Family: $12,900

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Bronze 21
30
40
50
60		 $175.28
$198.93
$223.89
$312.98
$475.38		 $350.56
$397.86
$447.78
$625.96
$950.76		 $461.72
$509.02
$558.94
$737.12		 $572.88
$620.18
$670.10
$848.28		 $684.04
$731.34
$781.26
$959.44		 $286.44
$310.09
$335.05
$424.14		 $397.60
$421.25
$446.21
$535.30		 $508.76
$532.41
$557.37
$646.46		 $111.16

Plan: (HMO) KP VA Catastrophic 6850/0/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $6,850 : Family: $13,700
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Catastrophic 21
30
40
50
60		 $153.79
$174.54
$196.45
$274.61
$417.10		 $307.58
$349.08
$392.90
$549.22
$834.20		 $405.11
$446.61
$490.43
$646.75		 $502.64
$544.14
$587.96
$744.28		 $600.17
$641.67
$685.49
$841.81		 $251.32
$272.07
$293.98
$372.14		 $348.85
$369.60
$391.51
$469.67		 $446.38
$467.13
$489.04
$567.20		 $97.53

Plan: (HMO) KP VA Platinum 0/20/Dental/Ped Dental

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-807-1140 - Provider Directory for This Plan: (Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:
Metal level Age Individual
 Couple
Couple
w 1 Kid
 Couple
w 2 Kids
 Couple
w3+Kids
 Single
w 1 Kid
 Single
w 2 Kids
 Single
w3+Kids
 Child
any age
Platinum 21
30
40
50
60		 $320.24
$363.45
$409.06
$571.82
$868.54		 $640.48
$726.90
$818.12
$1143.64
$1737.08		 $843.57
$929.99
$1021.21
$1346.73		 $1046.66
$1133.08
$1224.30
$1549.82		 $1249.75
$1336.17
$1427.39
$1752.91		 $523.33
$566.54
$612.15
$774.91		 $726.42
$769.63
$815.24
$978.00		 $929.51
$972.72
$1018.33
$1181.09		 $203.09

†Source: Our summary of lowest costs and numbers of providers is based on a government report released September 25, 2013. For more detailed information about specific plans and providers, see HealthCare.gov.

‡Source: HealthCare.gov has released sample rates for all counties in the 36 states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Loudoun County here.

 

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