BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay) - 40788TX0460003 Health Insurance Plan
Scott and White Health Plan health insurance plan with the Plan ID 40788TX0460003. The plan is called BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.06% (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 5.94% 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 | 40788TX0460003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | Scott and White Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 40788TX0460003-06 | ||||||||||||||||||
| Provider Network(s) | NETWORK BSWPREMIERHMO | ||||||||||||||||||
| 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 - 40788TX0460003-00 Standard On Exchange Plan - 40788TX0460003-01 Open to Indians below 300% FPL - 40788TX0460003-02 Open to Indians above 300% FPL - 40788TX0460003-03 73% AV Silver Plan - 40788TX0460003-04 |
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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 BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay) Health Insurance Plan, 40788TX0460003-06
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 25.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 25.00% |
100.00% |
| Autism Spectrum Disorders
Copay applies for office visits. All other outpatient benefits will pay at the same cost share level as any other medical/surgical benefit. Certain services require preauthorization. |
YES | $0.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Brain Injury
|
YES | 25.00% |
100.00% |
| Chemotherapy
|
YES | 25.00% |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year |
YES | $0.00 |
100.00% |
| Cosmetic Surgery
Covered only if necessary to improve the function of, or to attempt to create a normal appearance of an abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infection or disease. |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section. |
YES | 25.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | $0.00 |
100.00% |
| Diabetes Education
|
YES | $0.00 |
100.00% |
| Dialysis
|
YES | 25.00% |
100.00% |
| Durable Medical Equipment
|
YES | 25.00% |
100.00% |
| Emergency Room Services
|
YES | 25.00% |
25.00% |
| Emergency Transportation/Ambulance
|
YES | 25.00% |
25.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year 1 pair of glasses (lenses and frames) per year |
YES | $10.00 |
100.00% |
| Gender Affirming Care
Certain services require preauthorization. |
YES | 25.00% |
100.00% |
| Generic Drugs
If copay applies, copay amount is for 30 day supply. Copay for 90 day supply is three times the copay for 30 day supply. |
YES | $0.00 |
100.00% |
| Habilitation Services
Limit: 35.0 Visit(s) per Year |
YES | $0.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years To restore or correct impaired speech or hearing loss. |
YES | 25.00% |
100.00% |
| Home Health Care Services
Limit: 60.0 Days per Year |
YES | 25.00% |
100.00% |
| Hospice Services
Preauthorization is required. |
YES | 25.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% |
100.00% |
| Infertility Treatment
Diagnosis covered but treatment not covered. |
NO | ||
| Infusion Therapy
|
YES | 25.00% |
100.00% |
| Inherited Metabolic Disorder - PKU
|
YES | 25.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required. |
YES | 25.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% |
100.00% |
| Laboratory Outpatient and Professional Services
Refer to Plan Document for cost associated with certain outpatient laboratory and professional services. |
YES | 25.00% |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Certain services require preauthorization. |
YES | 25.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
Copay applies for office visits. All other outpatient benefits will pay at the same cost share level as any other medical/surgical benefit. Certain services require preauthorization. |
YES | $0.00 |
100.00% |
| Non-Preferred Brand Drugs
If copay applies, copay amount is for 30 day supply. Copay for 90 day supply is three times the copay for 30 day supply. |
YES | $50.00 |
100.00% |
| Nutritional Counseling
Copay waived if provided as preventive care. |
YES | $0.00 |
100.00% |
| Off Label Prescription Drugs
|
YES | 25.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered at no cost for dependent members through the age of 18. |
YES | $0.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year |
YES | $0.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% |
100.00% |
| Pediatric Services Other
|
YES | 25.00% |
100.00% |
| Post-Mastectomy Care
|
YES | 25.00% |
100.00% |
| Preferred Brand Drugs
If copay applies, copay amount is for 30 day supply. Copay for 90 day supply is three times the copay for 30 day supply. |
YES | $15.00 |
100.00% |
| Prenatal and Postnatal Care
No charge for prenatal visits; postnatal visits are covered at the PCP office visit copay. |
YES | $0.00 |
100.00% |
| Prescription Drugs Other
|
YES | 25.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Covered at no cost for dependent members through the age of 18. |
YES | $0.00 |
100.00% |
| Private-Duty Nursing
When pre-approved in a limited set of circumstances under the Home Health Care benefit. Refer to plan document. |
YES | 25.00% |
100.00% |
| Prosthetic Devices
Medically necessary foot orthotics are not subject to a calendar year maximum. |
YES | 25.00% |
100.00% |
| Radiation
|
YES | 25.00% |
100.00% |
| Reconstructive Surgery
|
YES | 25.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Year |
YES | $0.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per 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 |
YES | $10.00 |
100.00% |
| Routine Foot Care
Not covered for any services or supplies in connection with routine foot care, including the removal of warts, corns, or calluses. Or the cutting and trimming of toenails, in the absence of diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency. |
NO | ||
| Skilled Nursing Facility
Limit: 25.0 Days per Year |
YES | 25.00% |
100.00% |
| Specialist Visit
|
YES | $10.00 |
100.00% |
| Specialty Drugs
If copay applies, copay amount is for 30 day supply. |
YES | $150.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Certain services require preauthorization. |
YES | 25.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
Copay applies for office visits. All other outpatient benefits will pay at the same cost share level as any other medical/surgical benefit. Certain services require preauthorization. |
YES | $0.00 |
100.00% |
| Transplant
Preauthorization is required. |
YES | 25.00% |
100.00% |
| Transplant Donor Coverage
|
YES | 25.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. |
YES | 25.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $5.00 |
$5.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | $0.00 |
100.00% |
| X-rays and Diagnostic Imaging
Refer to Plan Document for cost associated with certain outpatient laboratory and professional services. |
YES | 25.00% |
100.00% |
BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay) Health Insurance Plan Variant 40788TX0460003-06 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.940590976666282 |
| 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 | 94% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | TXF002 |
| Formulary URL | URL |
| HIOS Product ID | 40788TX046 |
| 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 | 40788 |
| Issuer Marketplace Marketing Name | Baylor Scott and White Health Plan |
| 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 | TXN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Emergency Only |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 40788TX0460003-06 |
| Plan Marketing Name | BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay) |
| Plan Type | HMO |
| Plan Variant Marketing Name | BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,800 |
| 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 | $200 |
| SBC Scenario, Having Diabetes, Copayment | $300 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $30 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TXS001 |
| Source Name | HIOS |
| Plan ID | 40788TX0460003 |
| State Code | TX |
| 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 | $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 | $3600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $1800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $1,800 |
| 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 BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay) Health Insurance Plan, 40788TX0460003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay), 40788TX0460003 Health Insurance Plan, 40788TX0460003
-
Does BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay) Health Insurance Plan, 40788TX0460003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (40788TX0460003) Health Insurance Plan, Variant (40788TX0460003-06) offer Disease Management Programs?
Does (40788TX0460003) Health Insurance Plan, Variant (40788TX0460003-06) have Out Of Country Coverage?
Does (40788TX0460003) Health Insurance Plan, Variant (40788TX0460003-06) have Out of Service Area Coverage?
Does (40788TX0460003) Health Insurance Plan, Variant (40788TX0460003-06) offer Disease Management Programs?
Does BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay) Health Insurance Plan, Variant (40788TX0460003-06) offer Disease Management Programs for Asthma?
Does BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay) Health Insurance Plan, Variant (40788TX0460003-06) offer Disease Management Programs for Heart disease?
Does BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay) Health Insurance Plan, Variant (40788TX0460003-06) offer Disease Management Programs for Diabetes?
Does BSW Prime Silver HMO 003 (CMS Standardized Plan with $0 Pediatric PCP copay) Health Insurance Plan, Variant (40788TX0460003-06) 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