Balance by Medica Gold Standard - 21333OK0060055 Health Insurance Plan
Medica Insurance Company health insurance plan with the Plan ID 21333OK0060055. The plan is called Balance by Medica Gold Standard.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.02% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.98% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 21333OK0060055 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Oklahoma | ||||||||||||||||||
| Health Insurance Issuer | Medica Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 21333OK0060055-00 | ||||||||||||||||||
| 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 | Standard Off Exchange Plan - 21333OK0060055-00 Standard On Exchange Plan - 21333OK0060055-01 |
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| Last Plan Update Date | Sat, 16 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Balance by Medica Gold Standard Health Insurance Plan, 21333OK0060055-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Gender Affirming Care
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Generic Drugs
|
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Hearing Aids
One hearing aid per ear every 48 months. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Limit: 25.0 Visit(s) per Benefit Period Covered under Outpatient Therapy Services. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
50.00% 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 | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
|
YES | $60.00 |
100.00% |
| Nutritional Counseling
Diabetes self-management training and training related to medical nutrition therapy. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 30.0 Days per Benefit Period |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
Prescription insulin will not exceed $25 per prescription unit |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
50.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
Virtual visits are unlimited with a $0 copayment when provided by an in-network virtual care provider for non-urgent medical symptoms for common illnesses. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
Limit: 85.0 Visit(s) per Benefit Period |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Prosthetic Devices
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 25.0 Visit(s) per Benefit Period Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined). |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 25.0 Visit(s) per Benefit Period Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined). |
YES | $30.00 |
50.00% 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 | $30.00 |
50.00% Coinsurance after deductible |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Benefit Period |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| Specialty Drugs
|
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Transplant
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $45.00 |
$45.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
50.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Balance by Medica Gold Standard Health Insurance Plan Variant 21333OK0060055-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7801851164396751 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| 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 | OKF028 |
| Formulary URL | URL |
| HIOS Product ID | 21333OK006 |
| Import Date | 2023-12-16 01:02:09 |
| 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 | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | OKN006 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 21333OK0060055-00 |
| Plan Marketing Name | Balance by Medica Gold Standard |
| Plan Type | PPO |
| Plan Variant Marketing Name | Balance by Medica Gold Standard |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,300 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $1,100 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OKS006 |
| Source Name | HIOS |
| Plan ID | 21333OK0060055 |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $22500 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $11250 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $11,250 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| 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 Gold Standard Health Insurance Plan, 21333OK0060055
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Balance by Medica Gold Standard, 21333OK0060055 Health Insurance Plan, 21333OK0060055
-
Does Balance by Medica Gold Standard Health Insurance Plan, 21333OK0060055 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (21333OK0060055) Health Insurance Plan, Variant (21333OK0060055-00) offer Disease Management Programs?
Does (21333OK0060055) Health Insurance Plan, Variant (21333OK0060055-00) have Out Of Country Coverage?
Does (21333OK0060055) Health Insurance Plan, Variant (21333OK0060055-00) have Out of Service Area Coverage?
Does (21333OK0060055) Health Insurance Plan, Variant (21333OK0060055-00) offer Disease Management Programs?
Does Balance by Medica Gold Standard Health Insurance Plan, Variant (21333OK0060055-00) offer Disease Management Programs for Asthma?
Does Balance by Medica Gold Standard Health Insurance Plan, Variant (21333OK0060055-00) offer Disease Management Programs for Heart disease?
Does Balance by Medica Gold Standard Health Insurance Plan, Variant (21333OK0060055-00) offer Disease Management Programs for Depression?
Does Balance by Medica Gold Standard Health Insurance Plan, Variant (21333OK0060055-00) offer Disease Management Programs for Diabetes?
Does Balance by Medica Gold Standard Health Insurance Plan, Variant (21333OK0060055-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Balance by Medica Gold Standard Health Insurance Plan, Variant (21333OK0060055-00) offer Disease Management Programs for Low back pain?
Does Balance by Medica Gold Standard Health Insurance Plan, Variant (21333OK0060055-00) 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