Diabetes Silver Adult Vision & Fitness - 40356MI0020004 Health Insurance Plan
HAP CareSource health insurance plan with the Plan ID 40356MI0020004. The plan is called Diabetes Silver Adult Vision & Fitness.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.90% (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 12.10% 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 | 40356MI0020004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | HAP CareSource | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 40356MI0020004-05 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| 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 - 40356MI0020004-00 Standard On Exchange Plan - 40356MI0020004-01 Open to Indians below 300% FPL - 40356MI0020004-02 Open to Indians above 300% FPL - 40356MI0020004-03 73% AV Silver Plan - 40356MI0020004-04 |
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| Last Plan Update Date | Wed, 09 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Diabetes Silver Adult Vision & Fitness Health Insurance Plan, 40356MI0020004-05
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
NO | ||
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Limit combined with OT and PT. |
YES | $20.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | $250.00 Copay after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $250.00 Copay after deductible |
$250.00 Copay after deductible |
| Emergency Transportation/Ambulance
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 0.00% |
100.00% |
| Gender Affirming Care
Surgery determined to be Medically Necessary is Covered |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Select Diabetes Drugs and Supplies are covered at no charge. Refer to the plan brochure for more information. |
YES | $2.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Yearly limits: PT and OT: 30 visits, Speech: 30 visits. |
YES | $5.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Coverage includes inpatient and outpatient hospice care. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $200.00 Copay after deductible |
100.00% |
| Infertility Treatment
Underlying causes only. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $250.00 Copay per Stay after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $40.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | $250.00 Copay per Stay after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
The cost sharing that displays applies to office visits only. All other services are subject to the Outpatient Professional Services cost share.? |
YES | $5.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Limit: 6.0 Visit(s) per Year Dietician Services. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $5.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year PT/OT/Chiro - combined visits per contract year; 30 ST per contract year; 30 cardiac/pulmonary visits per contract year. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $20.00 |
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
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Combined with chiro. |
YES | $5.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year |
YES | $5.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
YES | No Charge |
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: 45.0 Days per Year |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $20.00 |
100.00% |
| Specialty Drugs
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $250.00 Copay per Stay after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
The cost sharing that displays applies to office visits only. All other services are subject to the Outpatient Professional Services cost share.? |
YES | $5.00 |
100.00% |
| Transplant
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Coverage includes medical care or services to treat dysfunction or TMJS 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 | 20.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $20.00 |
$20.00 |
| Weight Loss Programs
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $150.00 Copay after deductible |
100.00% |
Diabetes Silver 2 Adult Vision & Fitness Health Insurance Plan Variant 40356MI0020004-05 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.878971699278895 |
| 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 | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 0.9913614449597171 |
| First Tier Utilization | 100% |
| Formulary ID | MIF006 |
| Formulary URL | URL |
| HIOS Product ID | 40356MI002 |
| Import Date | 2024-10-09 20:01:46 |
| 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 | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 40356 |
| Issuer Marketplace Marketing Name | HAP CareSource |
| 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 | MIN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services Only |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 40356MI0020004-05 |
| Plan Marketing Name | Diabetes Silver Adult Vision & Fitness |
| Plan Type | HMO |
| Plan Variant Marketing Name | Diabetes Silver 2 Adult Vision & Fitness |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $300 |
| SBC Scenario, Having a Baby, Deductible | $800 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $60 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MIS001 |
| Source Name | SERFF |
| Plan ID | 40356MI0020004 |
| State Code | MI |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $6000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $3000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $3,000 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $1600 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $800 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $800 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1600 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $800 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $800 |
| 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 | $6000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $3000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,000 |
| 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 Diabetes Silver Adult Vision & Fitness Health Insurance Plan, 40356MI0020004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Diabetes Silver Adult Vision & Fitness, 40356MI0020004 Health Insurance Plan, 40356MI0020004
-
Does Diabetes Silver Adult Vision & Fitness Health Insurance Plan, 40356MI0020004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (40356MI0020004) Health Insurance Plan, Variant (40356MI0020004-05) offer Disease Management Programs?
Does (40356MI0020004) Health Insurance Plan, Variant (40356MI0020004-05) have Out Of Country Coverage?
Does (40356MI0020004) Health Insurance Plan, Variant (40356MI0020004-05) have Out of Service Area Coverage?
Does (40356MI0020004) Health Insurance Plan, Variant (40356MI0020004-05) offer Disease Management Programs?
Does Diabetes Silver 2 Adult Vision & Fitness Health Insurance Plan, Variant (40356MI0020004-05) offer Disease Management Programs for Asthma?
Does Diabetes Silver 2 Adult Vision & Fitness Health Insurance Plan, Variant (40356MI0020004-05) offer Disease Management Programs for Heart disease?
Does Diabetes Silver 2 Adult Vision & Fitness Health Insurance Plan, Variant (40356MI0020004-05) offer Disease Management Programs for Depression?
Does Diabetes Silver 2 Adult Vision & Fitness Health Insurance Plan, Variant (40356MI0020004-05) offer Disease Management Programs for Diabetes?
Does Diabetes Silver 2 Adult Vision & Fitness Health Insurance Plan, Variant (40356MI0020004-05) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Diabetes Silver 2 Adult Vision & Fitness Health Insurance Plan, Variant (40356MI0020004-05) offer Disease Management Programs for Low back pain?
Does Diabetes Silver 2 Adult Vision & Fitness Health Insurance Plan, Variant (40356MI0020004-05) offer Disease Management Programs for Pregnancy?
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