CHRISTUS Silver Essential Plus - 66252TX0340010 Health Insurance Plan
CHRISTUS Health Plan health insurance plan with the Plan ID 66252TX0340010. The plan is called CHRISTUS Silver Essential Plus.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.84% (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 29.16% 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 | 66252TX0340010 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 66252TX0340010-03 | ||||||||||||||||||
| Provider Network(s) | PREFERRED NONPREFERRED | ||||||||||||||||||
| 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 - 66252TX0340010-00 Standard On Exchange Plan - 66252TX0340010-01 Open to Indians below 300% FPL - 66252TX0340010-02 Open to Indians above 300% FPL - 66252TX0340010-03 73% AV Silver Plan - 66252TX0340010-04 |
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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 Plus Health Insurance Plan, 66252TX0340010-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 50% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $50.00 |
100.00% |
| Autism Spectrum Disorders
Texas State Required Benefit |
YES | $5.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
Limit: 1000.0 Dollars per Year Item and visit limits apply. $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 20.00% |
20.00% |
| Basic Dental Care - Child
|
YES | 20.00% |
20.00% |
| Brain Injury
Texas State Required Benefit |
YES | 50% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 50% Coinsurance after deductible |
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 | $50.00 |
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 Copay after deductible |
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% Coinsurance after deductible |
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% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $950 Copay after deductible |
$950 Copay after deductible |
| Emergency Transportation/Ambulance
|
YES | 50% Coinsurance after deductible |
50% Coinsurance after deductible |
| Eye Glasses for Adults
Limit: 1.0 Item(s) per Year Limited to one item per year up to $130 per person for either glasses or contacts. |
YES | 0.00% |
100.00% |
| 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 | $10.00 |
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 | $50.00 |
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% Coinsurance after deductible |
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% Coinsurance after deductible |
100.00% |
| Hospice Services
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | 50% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | $400 Copay after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | $50.00 |
100.00% |
| Inherited Metabolic Disorder - PKU
Texas State Required Benefit |
YES | 50% Coinsurance after deductible |
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 after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $60.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
Limit: 1000.0 Dollars per Year Item and visit limits apply. $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
50.00% |
| 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 after deductible |
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 | $50.00 |
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 Copay after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| Off Label Prescription Drugs
Texas State Required Benefit |
YES | 50% Coinsurance after deductible |
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 | $50.00 |
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% Coinsurance after deductible |
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 | $50.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | 50% Coinsurance after deductible |
100.00% |
| Pediatric Services Other
Texas State Required Benefit |
YES | 50% Coinsurance after deductible |
100.00% |
| Post-Mastectomy Care
Texas State Required Benefit |
YES | $50.00 |
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 | $50.00 |
100.00% |
| Prescription Drugs Other
Texas State Required Benefit |
YES | 50% Coinsurance after deductible |
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% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 50% Coinsurance after deductible |
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% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | $50.00 |
100.00% |
| Rehabilitative Speech Therapy
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | $50.00 |
100.00% |
| Routine Dental Services (Adult)
Limit: 1000.0 Dollars per Year Item and visit limits apply. $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults. |
YES | 0.00% |
0.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Year |
YES | 0.00% |
100.00% |
| 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% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $50.00 |
100.00% |
| Specialty Drugs
|
YES | $350 Copay after deductible |
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 after deductible |
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 | $50.00 |
100.00% |
| Transplant
Preauthorization is required. If you don't get preauthorization, benefits will be denied. |
YES | $950 Copay after deductible |
100.00% |
| Transplant Donor Coverage
Texas State Required Benefit |
YES | 50% Coinsurance after deductible |
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% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
No charge for virtual urgent care through CHRISTUS Health System. |
YES | $50.00 |
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 70 + Dental & Vision Limited ($5 PCP, $0 Preferred Generic Rx, $0 Virtual Urgent Care) Health Insurance Plan Variant 66252TX0340010-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.708357959759152 |
| 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 | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Diabetes |
| EHB Percent of Total Premium | 0.9834243505908249 |
| First Tier Utilization | 100% |
| Formulary ID | TXF006 |
| Formulary URL | URL |
| HIOS Product ID | 66252TX034 |
| 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 | New |
| 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) | 66252TX0340010-03 |
| Plan Marketing Name | CHRISTUS Silver Essential Plus |
| Plan Type | HMO |
| Plan Variant Marketing Name | CHRISTUS Silver Essential 70 + Dental & Vision Limited ($5 PCP, $0 Preferred Generic Rx, $0 Virtual Urgent Care) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,600 |
| SBC Scenario, Having a Baby, Deductible | $6,900 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,200 |
| SBC Scenario, Having Diabetes, Deductible | $800 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TXS010 |
| Source Name | HIOS |
| Plan ID | 66252TX0340010 |
| State Code | TX |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $9,200 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $13800 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $6900 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $6,900 |
| 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 | $13800 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6900 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,900 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $13800 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $6900 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $6,900 |
| 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 | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $9,200 |
| 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 Plus Health Insurance Plan, 66252TX0340010
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about CHRISTUS Silver Essential Plus, 66252TX0340010 Health Insurance Plan, 66252TX0340010
-
Does CHRISTUS Silver Essential Plus Health Insurance Plan, 66252TX0340010 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (66252TX0340010) Health Insurance Plan, Variant (66252TX0340010-03) offer Disease Management Programs?
Does (66252TX0340010) Health Insurance Plan, Variant (66252TX0340010-03) have Out Of Country Coverage?
Does (66252TX0340010) Health Insurance Plan, Variant (66252TX0340010-03) have Out of Service Area Coverage?
Does (66252TX0340010) Health Insurance Plan, Variant (66252TX0340010-03) offer Disease Management Programs?
Does CHRISTUS Silver Essential 70 + Dental & Vision Limited ($5 PCP, $0 Preferred Generic Rx, $0 Virtual Urgent Care) Health Insurance Plan, Variant (66252TX0340010-03) 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