Balance by Medica Catastrophic - 21333OK0060013 Health Insurance Plan
Medica Insurance Company health insurance plan with the Plan ID 21333OK0060013. The plan is called Balance by Medica Catastrophic.
| Health Insurance Plan ID | 21333OK0060013 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Oklahoma | ||||||||||||||||||
| Health Insurance Issuer | Medica Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 21333OK0060013-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED PREFERREDTIER STANDARDTIER | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Thu, 19 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Balance by Medica Catastrophic Health Insurance Plan, 21333OK0060013-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Chiropractic Care
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Dialysis
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Gender Affirming Care
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Generic Drugs
|
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period See policy or plan document for additional benefit explanation. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Hearing Aids
See policy or plan document for additional benefit explanation. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | No Charge after deductible |
100.00% |
| Hospice Services
|
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Limit: 25.0 Visit(s) per Benefit Period See policy or plan document for additional benefit explanation. |
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
See policy or plan document for additional benefit explanation. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 30.0 Days per Benefit Period See policy or plan document for additional benefit explanation. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
30.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 Copay with deductible, No Charge after deductible |
30.00% Coinsurance after deductible |
| Private-Duty Nursing
Limit: 85.0 Visit(s) per Benefit Period |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Prosthetic Devices
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Radiation
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Reconstructive Surgery
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 25.0 Visit(s) per Benefit Period See policy or plan document for additional benefit explanation. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 25.0 Visit(s) per Benefit Period See policy or plan document for additional benefit explanation. |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Benefit Period |
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Specialist Visit
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Specialty Drugs
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Transplant
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
No Charge after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
30.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
30.00% Coinsurance after deductible |
Balance by Medica Catastrophic Health Insurance Plan Variant 21333OK0060013-00 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 3 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Catastrophic Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | OKF010 |
| Formulary URL | URL |
| HIOS Product ID | 21333OK006 |
| Import Date | 2024-09-19 01:01:32 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 21333 |
| Issuer Marketplace Marketing Name | Medica |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Catastrophic |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | OKN006 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services and Out of Network services received in the state of Oklahoma |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 21333OK0060013-00 |
| Plan Marketing Name | Balance by Medica Catastrophic |
| Plan Type | PPO |
| Plan Variant Marketing Name | Balance by Medica Catastrophic |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $9,200 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $90 |
| SBC Scenario, Having Diabetes, Deductible | $2,300 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OKS006 |
| Source Name | HIOS |
| Plan ID | 21333OK0060013 |
| State Code | OK |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $18400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $9200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $9,200 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $55200 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $27600 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $27,600 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Balance by Medica Catastrophic Health Insurance Plan, 21333OK0060013
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Balance by Medica Catastrophic, 21333OK0060013 Health Insurance Plan, 21333OK0060013
-
Does Balance by Medica Catastrophic Health Insurance Plan, 21333OK0060013 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (21333OK0060013) Health Insurance Plan, Variant (21333OK0060013-00) offer Disease Management Programs?
Does (21333OK0060013) Health Insurance Plan, Variant (21333OK0060013-00) have Out Of Country Coverage?
Does (21333OK0060013) Health Insurance Plan, Variant (21333OK0060013-00) have Out of Service Area Coverage?
Does (21333OK0060013) Health Insurance Plan, Variant (21333OK0060013-00) offer Disease Management Programs?
Does Balance by Medica Catastrophic Health Insurance Plan, Variant (21333OK0060013-00) offer Disease Management Programs for Asthma?
Does Balance by Medica Catastrophic Health Insurance Plan, Variant (21333OK0060013-00) offer Disease Management Programs for Heart disease?
Does Balance by Medica Catastrophic Health Insurance Plan, Variant (21333OK0060013-00) offer Disease Management Programs for Depression?
Does Balance by Medica Catastrophic Health Insurance Plan, Variant (21333OK0060013-00) offer Disease Management Programs for Diabetes?
Does Balance by Medica Catastrophic Health Insurance Plan, Variant (21333OK0060013-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Balance by Medica Catastrophic Health Insurance Plan, Variant (21333OK0060013-00) offer Disease Management Programs for Low back pain?
Does Balance by Medica Catastrophic Health Insurance Plan, Variant (21333OK0060013-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API