CHRISTUS Silver Essential - 66252TX0160010 Health Insurance Plan
CHRISTUS Health Plan health insurance plan with the Plan ID 66252TX0160010. The plan is called CHRISTUS Silver Essential.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.74% (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 12.26% 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 | 66252TX0160010 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | CHRISTUS Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 66252TX0160010-05 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 26 Nov 2024 06:27 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 66252TX0160010-00 Standard On Exchange Plan - 66252TX0160010-01 Open to Indians below 300% FPL - 66252TX0160010-02 Open to Indians above 300% FPL - 66252TX0160010-03 73% AV Silver Plan - 66252TX0160010-04 |
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| Last Plan Update Date | Tue, 24 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 26 Nov 2024 06:27 GMT |
Benefits of CHRISTUS Silver Essential Health Insurance Plan, 66252TX0160010-05
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 50.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $35.00 |
100.00% |
| Autism Spectrum Disorders
Texas State Required Benefit |
YES | $5.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | 20.00% |
20.00% |
| Brain Injury
Texas State Required Benefit |
YES | 50.00% |
100.00% |
| Chemotherapy
|
YES | 50.00% |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Outpatient Rehabilitation Services. Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | $35.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Preauthorization is required for inpatient care, except for: (1) forty-eight (48) hours of Inpatient care following an uncomplicated vaginal delivery or ninety-six (96) hours of Inpatient care following an uncomplicated Cesarean section or (2) Post-Partum Care. If you don?t get preauthorization, benefits will be denied. |
YES | $950.00 |
100.00% |
| Dental Check-Up for Children
One visit and exam every 6 months |
YES | 0.00% |
0.00% |
| Diabetes Care Management
Texas State Required Benefit |
YES | $5.00 |
100.00% |
| Diabetes Education
|
YES | 0.00% |
100.00% |
| Dialysis
|
YES | 50.00% |
100.00% |
| Durable Medical Equipment
Preauthorization is required for some durable medical equipment. If you don't get preauthorization, benefits will be denied. |
YES | 50.00% |
100.00% |
| Emergency Room Services
|
YES | $950.00 |
$950.00 |
| Emergency Transportation/Ambulance
|
YES | 50.00% |
50.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 0.00% |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Cost sharing for a 90-day supply by mail order is triple the cost sharing for a standard 30-day supply. Prescriptions for birth control are not subject to deductible, and do not have a copayment. |
YES | $0.00 |
100.00% |
| Habilitation Services
Habilitative and rehabilitative limits cannot be combined for plans issued or renewed on or after January 1, 2017. Habilitation services includes autism services, and the benchmark plan does not impose age or maximums on autism coverage. MH/SUD office visits are subject to the listed cost sharing, while MH/SUD facility outpatient treatments are subject to the outpatient facility coinsurance. Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | $35.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years To restore or correction of impaired speech or hearing loss. 1 hearing aid in each ear every 3 years limited to $2,000 benefit maximum per device |
YES | 50.00% |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | 50.00% |
100.00% |
| Hospice Services
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | 50.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | $400.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | $35.00 |
100.00% |
| Inherited Metabolic Disorder - PKU
Texas State Required Benefit |
YES | 50.00% |
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. If you don't get preauthorization, benefits will be denied. |
YES | $950 Copay per Stay |
100.00% |
| Inpatient Physician and Surgical Services
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $60.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | 50.00% |
50.00% |
| Mental/Behavioral Health Inpatient Services
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | $950 Copay per Stay |
100.00% |
| Mental/Behavioral Health Outpatient Services
MH/SUD office visits are subject to the listed cost sharing, while MH/SUD facility outpatient treatments are subject to the outpatient facility coinsurance. |
YES | $35.00 |
100.00% |
| Non-Preferred Brand Drugs
Cost sharing for a 90-day supply by mail order is triple the cost sharing for a standard 30-day supply. Prescriptions for birth control are not subject to deductible, and do not have a copayment. |
YES | $80.00 |
100.00% |
| Nutritional Counseling
|
NO | ||
| Off Label Prescription Drugs
Texas State Required Benefit |
YES | 50.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Medically necessary. Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | 50.00% |
50.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $35.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | 50.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | $35.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | 50.00% |
100.00% |
| Pediatric Services Other
Texas State Required Benefit |
YES | 50.00% |
100.00% |
| Post-Mastectomy Care
Texas State Required Benefit |
YES | $35.00 |
100.00% |
| Preferred Brand Drugs
Cost sharing for a 90-day supply by mail order is triple the cost sharing for a standard 30-day supply. Prescriptions for birth control are not subject to deductible, and do not have a copayment. |
YES | $60.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $35.00 |
100.00% |
| Prescription Drugs Other
Texas State Required Benefit |
YES | 50.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $5.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Medically necessary foot orthotics are not subject to a calendar year maximum. |
YES | 50.00% |
100.00% |
| Radiation
|
YES | 50.00% |
100.00% |
| Reconstructive Surgery
Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. |
YES | 50.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | $35.00 |
100.00% |
| Rehabilitative Speech Therapy
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | $35.00 |
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 | 0.00% |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 25.0 Days per Year Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | 50.00% |
100.00% |
| Specialist Visit
|
YES | $35.00 |
100.00% |
| Specialty Drugs
|
YES | $350.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | $950 Copay per Stay |
100.00% |
| Substance Abuse Disorder Outpatient Services
MH/SUD office visits are subject to the listed cost sharing, while MH/SUD facility outpatient treatments are subject to the outpatient facility coinsurance. |
YES | $35.00 |
100.00% |
| Transplant
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | $950.00 |
100.00% |
| Transplant Donor Coverage
Texas State Required Benefit |
YES | 50.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Though state law only mandates coverage for temporomandibular joint (TMJ) disorders for large group plans and HMOs, the benchmark plan covers TMJ. Therefore, it is considered part of the EHB package for Texas. |
YES | 50.00% |
100.00% |
| Urgent Care Centers or Facilities
No charge for virtual urgent care through CHRISTUS Health System. |
YES | $35.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $60.00 |
100.00% |
CHRISTUS Silver Essential 87 ($0 Deductible, $5 PCP, $0 Generic Rx, $0 Virtual Urgent Care) Health Insurance Plan Variant 66252TX0160010-05 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.877361526058769 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | 87% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Diabetes |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | TXF006 |
| Formulary URL | URL |
| HIOS Product ID | 66252TX016 |
| Import Date | 2024-09-24 01:01:39 |
| 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 | 66252 |
| Issuer Marketplace Marketing Name | CHRISTUS 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 | Yes |
| Out of Country Coverage Description | Emergency Services |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 66252TX0160010-05 |
| Plan Marketing Name | CHRISTUS Silver Essential |
| Plan Type | HMO |
| Plan Variant Marketing Name | CHRISTUS Silver Essential 87 ($0 Deductible, $5 PCP, $0 Generic Rx, $0 Virtual Urgent Care) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,300 |
| SBC Scenario, Having a Baby, Copayment | $1,600 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $400 |
| SBC Scenario, Having Diabetes, Copayment | $1,000 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $700 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TXS010 |
| Source Name | HIOS |
| Plan ID | 66252TX0160010 |
| State Code | TX |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $6100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $3050 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $3,050 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| 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 | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $6100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $3050 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,050 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $6100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $3050 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $3,050 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of CHRISTUS Silver Essential Health Insurance Plan, 66252TX0160010
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about CHRISTUS Silver Essential, 66252TX0160010 Health Insurance Plan, 66252TX0160010
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Does CHRISTUS Silver Essential Health Insurance Plan, 66252TX0160010 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (66252TX0160010) Health Insurance Plan, Variant (66252TX0160010-05) offer Disease Management Programs?
Does (66252TX0160010) Health Insurance Plan, Variant (66252TX0160010-05) have Out Of Country Coverage?
Does (66252TX0160010) Health Insurance Plan, Variant (66252TX0160010-05) have Out of Service Area Coverage?
Does (66252TX0160010) Health Insurance Plan, Variant (66252TX0160010-05) offer Disease Management Programs?
Does CHRISTUS Silver Essential 87 ($0 Deductible, $5 PCP, $0 Generic Rx, $0 Virtual Urgent Care) Health Insurance Plan, Variant (66252TX0160010-05) offer Disease Management Programs for Diabetes?
Disclaimer: This is based on the import(Date: Tue, 26 Nov 2024 06:27 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