Blue Cross® Local HMO Silver Extra - 98185MI0550019 Health Insurance Plan
Blue Care Network of Michigan health insurance plan with the Plan ID 98185MI0550019. The plan is called Blue Cross® Local HMO Silver Extra.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 98185MI0550019 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Blue Care Network of Michigan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 98185MI0550019-02 | ||||||||||||||||||
| Provider Network(s) | ['MIN007'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 98185MI0550019-00 Standard On Exchange Plan - 98185MI0550019-01 Open to Indians below 300% FPL - 98185MI0550019-02 Open to Indians above 300% FPL - 98185MI0550019-03 73% AV Silver Plan - 98185MI0550019-04 |
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| Last Plan Update Date | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Blue Cross® Local HMO Silver Extra Health Insurance Plan, 98185MI0550019-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Accidental injury and emergency only. |
YES | 0.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
In network only if at a physican's office. |
YES | 0.00% |
100.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime Prior authorization required. The penalty for not having prior authorization is denial of payment. |
YES | 0.00% |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 0.00% |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Spinal manipulation limit is not combined with Occupational Therapy and Physical Therapy; limit includes services provided by an osteopathic provider. |
YES | 0.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Prior authoriztion required. The penalty for not having prior authorization is denial of payment. |
YES | 0.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Follow Medicare guidelines. |
YES | 0.00% |
100.00% |
| Dialysis
|
YES | 0.00% |
100.00% |
| Durable Medical Equipment
Exclusions: Excludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription is required. Rental and purchase limited to basic equipment. Prior authoriztion required. The penalty for not having prior authorization is denial of payment. Breast pumps are covered in full when preauthorized. |
YES | 0.00% |
100.00% |
| Emergency Room Services
Emergency room visits will be covered at non-participating facilities for medical emergencies and accidental injuries only. Copayment waived if admitted inpatient into the hospital. |
YES | 0.00% |
0.00% |
| Emergency Transportation/Ambulance
Exclusions: Transportation for convenience. Includes air and ground transportation. |
YES | 0.00% |
0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Out of network is paid up to the allowed amount. A child is defined as a member up to age 19. |
YES | $0.00 |
100.00% |
| Gender Affirming Care
Exclusions: Cosmetic surgery, investigational and experimental procedures. May require prior authorization. |
YES | 0.00% |
100.00% |
| Generic Drugs
Exclusions: Quantity limits per fill may apply for 30-day retail, 90-day retail, and 90-day mail order. Opioid containing medications are limited to no more than a 30-day supply per fill and first fills of select opioid containing medications will be limited to a 5-day supply. Refer to drug list for quantity limits and other exclusions. May require prior authorization & step therapy. The penalty for not having prior authorization is denial of payment. No charge for Tier 1A contraceptives. Any coupon, rebate, or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer?s deductible, cost-sharing or out of pocket maximum |
YES | $0.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Prior authoriztion required. The penalty for not having prior authorization is denial of payment. Physical Therapy/Occupational Therapy- combined 30 visits per calendar year; 30 visits for Speech Therapy per calendar year. |
YES | $0.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Exclusions: Housekeeping Services. Services for the purposes of custodial care. BCN approved providers only. |
YES | 0.00% |
100.00% |
| Hospice Services
Exclusions: Housekeeping services. Room and board at an extended care facility or hospice facility for the purposes of delivering Custodial Care. Prior authorization required. The penalty for not having prior authorization is denial of payment. BCN participating hospice programs only. Coverage includes inpatient and outpatient hospice care. |
YES | $0.00 |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Prior authoriztion required. The penalty for not having prior authorization is denial of payment. |
YES | 0.00% |
100.00% |
| Infertility Treatment
Exclusions: Artificial Insemination and In-Vitro Fertilization. Prior authorization required. The penalty for not having prior authorization is denial of payment. |
YES | 0.00% |
100.00% |
| Infusion Therapy
BCN approved providers only. |
YES | 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Prior authorization required. The penalty for not having prior authorization is denial of payment. |
YES | 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
The penalty for not having prior authorization is denial of payment. |
YES | 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
May require prior authorization. The penalty for not having prior authorization is denial of payment. |
YES | 0.00% |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Prior authoriztion required. The penalty for not having prior authorization is denial of payment. |
YES | 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
Copayment?applies to?provider?s?office, virtual visit?by participating BCN provider and Blue Cross online visit from BCN selected vendor only. Additional services are subject to the plan's deductible and coinsurance. Prior authorization is not required for outpatient, office and online visits. Prior authorization is required for other outpatient services. |
YES | $0.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: Quantity limits per fill may apply for 30-day retail, 90-day retail, and 90-day mail order. Opioid containing medications are limited to no more than a 30-day supply per fill and first fills of select opioid containing medications will be limited to a 5-day supply. Refer to drug list for quantity limits and other exclusions. May require prior authorization & step therapy. The penalty for not having prior authorization is denial of payment. No charge for Tier 1A contraceptives. Any coupon, rebate, or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer?s deductible, cost-sharing or out of pocket maximum |
YES | $0.00 |
100.00% |
| Nutritional Counseling
Dietician Services. |
YES | $0.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Includes virtual and retail health clinic visits. No charge for 24/7 medical virtual visits when performed through the BCN selected vendor app. Diagnostic services are not included in the office visit?copayment. These services are subject to the?plan's?deductible?and?coinsurance, if applicable. |
YES | $0.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: Cosmetic surgery, corrective eye surgery, investigational and experimental procedures. May require prior authorization. |
YES | 0.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Prior authoriztion required. The penalty for not having prior authorization is denial of payment. Physical Therapy/Occupational Therapy- combined 30 visits per calendar year; 30 visits for Speech Therapy per calendar year. |
YES | $0.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: Cosmetic surgery, corrective eye surgery, investigational and experimental procedures. May require prior authorization. |
YES | 0.00% |
100.00% |
| Preferred Brand Drugs
Exclusions: Quantity limits per fill may apply for 30-day retail, 90-day retail, and 90-day mail order. Opioid containing medications are limited to no more than a 30-day supply per fill and first fills of select opioid containing medications will be limited to a 5-day supply. Refer to drug list for quantity limits and other exclusions. May require prior authorization & step therapy. The penalty for not having prior authorization is denial of payment. No charge for Tier 1A contraceptives. Any coupon, rebate, or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer?s deductible, cost-sharing or out of pocket maximum |
YES | $0.00 |
100.00% |
| Prenatal and Postnatal Care
Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance, or deductible may apply. |
YES | $0.00 |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: Care and services not defined as preventive under PPACA. May require prior authorization. The penalty for not having prior authorization is denial of payment. You may have to pay for services that aren?t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Includes virtual and retail health clinic visits. No charge for 24/7 medical virtual visits when performed through the BCN selected vendor app. Diagnostic services are not included in the office visit?copayment. These services are subject to the?plan's?deductible?and?coinsurance, if applicable. |
YES | $0.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
BCN approved providers only. Limited to the basic items; replacement is limited to items that cannot be repaired or modified |
YES | 0.00% |
100.00% |
| Radiation
|
YES | 0.00% |
100.00% |
| Reconstructive Surgery
Covered only when medically necessary. |
YES | 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Prior authoriztion required. The penalty for not having prior authorization is denial of payment. Physical Therapy/Occupational Therapy- combined 30 visits per calendar year; 30 visits for Speech Therapy per calendar year. |
YES | $0.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Prior authoriztion required. The penalty for not having prior authorization is denial of payment. Physical Therapy/Occupational Therapy- combined 30 visits per calendar year; 30 visits for Speech Therapy per calendar year. |
YES | $0.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Out of network is paid up to the allowed amount. A child is defined as a member up to age 19. |
YES | $0.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 45.0 Days per Year Exclusions: Custodial Care. Prior authoriztion required. The penalty for not having prior authorization is denial of payment. BCN participating facilities only. |
YES | 0.00% |
100.00% |
| Specialist Visit
Referral required. The penalty for not having a referral is denial of payment. Diagnostic services are not included in the office visit copayment. These services are subject to the plan's deductible and coinsurance, if applicable. No charge for 24/7 medical virtual visits when performed through the BCN selected vendor app. |
YES | $0.00 |
100.00% |
| Specialty Drugs
Exclusions: Specialty drugs are limited to a 30-day supply per fill, however some may be limited to a 15-day supply fill, depending on the medication Refer to drug list for quantity limits and other exclusions. BCN has contracted with an exclusive pharmacy network for specialty drugs. Call the customer service phone number on the back of your ID card for the pharmacy?s phone number or location nearest to you. If you obtain your specialty drugs from any other pharmacy, you are responsible for the total cost. Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer?s deductible, cost-sharing or out of pocket maximum |
YES | $0.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Prior authoriztion required. The penalty for not having prior authorization is denial of payment. |
YES | 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
Copayment?applies to?provider?s?office, virtual visit?by participating BCN provider and Blue Cross online visit from BCN selected vendor only. Additional services are subject to the plan's deductible and coinsurance. Prior authorization is not required for outpatient, office and online visits. Prior authorization is required for other outpatient services. |
YES | $0.00 |
100.00% |
| Transplant
Subject to BCN medical criteria. BCN designated facility only. |
YES | 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: Dental and orthodontic services, treatment, prosthesis and appliances related to TMJ. Prior authorization required. The penalty for not having prior authorization is denial of payment. Coverage includes medical care or services to treat dysfunction or TMJ resulting from a medical cause or Injury, Office visits for medical evaluation and treatment, X-rays of the temporomandibular joint including contrast studies, but not dental x-rays, Myofunctional therapy and Surgery to the temporomandibular joint, such as condylectomy, meniscectomy, arthrotomy, and arthrocentesis. |
YES | 0.00% |
100.00% |
| Urgent Care Centers or Facilities
Urgent Care visits will be covered at non-participating providers for medical emergencies and accidental injuries only. |
YES | $0.00 |
$0.00 |
| Weight Loss Programs
Obesity screening at physician's office only. |
YES | $0.00 |
100.00% |
| Well Baby Visits and Care
Quantity limits based on PPACA. |
YES | $0.00 |
100.00% |
| X-rays and Diagnostic Imaging
May require prior authorization. The penalty for not having prior authorization is denial of payment. |
YES | 0.00% |
100.00% |
Blue Cross® Local HMO Silver Extra Health Insurance Plan Variant 98185MI0550019-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| 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 | Zero Cost Sharing Plan Variation |
| 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, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | MIF232 |
| Formulary URL | URL |
| HIOS Product ID | 98185MI055 |
| Import Date | 2023-08-16 20:01:48 |
| 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? | Yes |
| Issuer ID | 98185 |
| Issuer Marketplace Marketing Name | Blue Care Network of Michigan |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MIN007 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Accidential Injury and Emergency Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Accidential Injury and Emergency Only |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 98185MI0550019-02 |
| Plan Marketing Name | Blue Cross® Local HMO Silver Extra |
| Plan Type | HMO |
| Plan Variant Marketing Name | Blue Cross® Local HMO Silver Extra |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MIS006 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All except routine OB/GYN & pediatric visits |
| Plan ID | 98185MI0550019 |
| State Code | MI |
| 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 | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| 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 Blue Cross® Local HMO Silver Extra Health Insurance Plan, 98185MI0550019
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Cross® Local HMO Silver Extra, 98185MI0550019 Health Insurance Plan, 98185MI0550019
-
Does Blue Cross® Local HMO Silver Extra Health Insurance Plan, 98185MI0550019 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (98185MI0550019) Health Insurance Plan, Variant (98185MI0550019-02) offer Disease Management Programs?
Does (98185MI0550019) Health Insurance Plan, Variant (98185MI0550019-02) have Out Of Country Coverage?
Does (98185MI0550019) Health Insurance Plan, Variant (98185MI0550019-02) have Out of Service Area Coverage?
Does (98185MI0550019) Health Insurance Plan, Variant (98185MI0550019-02) offer Disease Management Programs?
Does Blue Cross® Local HMO Silver Extra Health Insurance Plan, Variant (98185MI0550019-02) offer Disease Management Programs for Asthma?
Does Blue Cross® Local HMO Silver Extra Health Insurance Plan, Variant (98185MI0550019-02) offer Disease Management Programs for Heart disease?
Does Blue Cross® Local HMO Silver Extra Health Insurance Plan, Variant (98185MI0550019-02) offer Disease Management Programs for Depression?
Does Blue Cross® Local HMO Silver Extra Health Insurance Plan, Variant (98185MI0550019-02) offer Disease Management Programs for Diabetes?
Does Blue Cross® Local HMO Silver Extra Health Insurance Plan, Variant (98185MI0550019-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Blue Cross® Local HMO Silver Extra Health Insurance Plan, Variant (98185MI0550019-02) offer Disease Management Programs for Low back pain?
Does Blue Cross® Local HMO Silver Extra Health Insurance Plan, Variant (98185MI0550019-02) offer Disease Management Programs for Pregnancy?
Does Blue Cross® Local HMO Silver Extra Health Insurance Plan, Variant (98185MI0550019-02) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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