Elite Gold + Vision + Adult Dental - 58594MI0040023 Health Insurance Plan

Meridian Health Plan of Michigan, Inc. health insurance plan with the Plan ID 58594MI0040023. The plan is called Elite Gold + Vision + Adult Dental.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.80% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.20% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 82.87% (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 17.13% 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 58594MI0040023
Health Insurance Plan Year 2025
State Michigan
Health Insurance Issuer Meridian Health Plan of Michigan, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 58594MI0040023-00
Provider Network(s) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 17 Dec 2024 06:12 GMT).

Providers Michigan All US States
All 191 8197
PCP 31 1103
Allergy 1 6
OB/GYN 1 39
Dentists 5 803
Available Variants of the Health Plan

Standard Off Exchange Plan - 58594MI0040023-00

Standard On Exchange Plan - 58594MI0040023-01

Open to Indians below 300% FPL - 58594MI0040023-02

Open to Indians above 300% FPL - 58594MI0040023-03

Last Plan Update Date Tue, 13 Aug 2024 00:00 GMT
Last Import Date Tue, 17 Dec 2024 06:12 GMT

Benefits of Elite Gold + Vision + Adult Dental Health Insurance Plan, 58594MI0040023-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

$200.00

100.00%
Acupuncture
NO
Allergy Testing
YES

$60.00

100.00%
Bariatric Surgery

Limit: 1.0 Procedure(s) per Lifetime

YES

30.00%

100.00%
Basic Dental Care - Adult

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

YES

50.00%

100.00%
Basic Dental Care - Child
NO
Chemotherapy
YES

$200.00

100.00%
Chiropractic Care

Limit: 30.0 Visit(s) per Year

Limited to 30 combined visits per year (combined for occupational therapy, physical therapy and chiropractic care). Limited to 30 visits per year speech therapy. Limited to 30 visits per year cardiac therapy. Limited to 30 visits per year pulmonary therapy.

YES

$60.00

100.00%
Cosmetic Surgery

See Reconstructive Surgery.

NO
Delivery and All Inpatient Services for Maternity Care
YES

30.00%

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

$60.00

100.00%
Dialysis
YES

$200.00

100.00%
Durable Medical Equipment
YES

30.00%

100.00%
Emergency Room Services
YES

30.00%

30.00%
Emergency Transportation/Ambulance

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

YES

30.00%

30.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

No Charge

100.00%
Gender Affirming Care
YES

30.00%

100.00%
Generic Drugs

Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information.

YES

$3.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Year

Limited to 30 combined visits per year (combined for occupational therapy, physical therapy and chiropractic care). Limited to 30 visits per year speech therapy. Limited to 30 visits per year cardiac therapy. Limited to 30 visits per year pulmonary therapy.

YES

$50.00

100.00%
Hearing Aids

Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit.

NO
Home Health Care Services
YES

30.00%

100.00%
Hospice Services

Respite Care is covered as part of hospice services only.

YES

30.00%

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$75.00

100.00%
Infertility Treatment

Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).

YES

$200.00

100.00%
Infusion Therapy
YES

$200.00

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

30.00%

100.00%
Inpatient Physician and Surgical Services
YES

30.00%

100.00%
Laboratory Outpatient and Professional Services
YES

$40.00

100.00%
Long-Term/Custodial Nursing Home Care

Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit.

NO
Major Dental Care - Adult

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

YES

50.00%

100.00%
Major Dental Care - Child
NO
Mental/Behavioral Health Emergency Room
YES

30.00%

30.00%
Mental/Behavioral Health Emergency Transportation/Ambulance

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

YES

30.00%

30.00%
Mental/Behavioral Health ER Physician Fee
YES

30.00%

30.00%
Mental/Behavioral Health Inpatient Services

Prior authorization may be required - please contact the number listed on your ID card.

YES

30.00%

100.00%
Mental/Behavioral Health Outpatient Other Services
YES

$200.00

100.00%
Mental/Behavioral Health Outpatient Services

Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization.

YES

$5.00

100.00%
Mental/Behavioral Health Urgent Care
YES

$35.00

100.00%
Non-Preferred Brand Drugs
YES

45.00%

100.00%
Nutritional Counseling

Limit: 6.0 Visit(s) per Year

Weight loss programs under the supervision of a physician & obesity counseling.

YES

$60.00

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

$200.00

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Year

Limited to 30 combined visits per year (combined for occupational therapy, physical therapy and chiropractic care). Limited to 30 visits per year speech therapy. Limited to 30 visits per year cardiac therapy. Limited to 30 visits per year pulmonary therapy.

YES

$50.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$200.00

100.00%
Preferred Brand Drugs
YES

$50.00

100.00%
Prenatal and Postnatal Care
YES

$5.00

100.00%
Preventive Care/Screening/Immunization

Covered in accordance with ACA guidelines.

YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

Unlimited Virtual 24/7 Care Visits received from Ambetter?s designated telehealth provider covered at No Charge, except for HSAs.

YES

$5.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

30.00%

100.00%
Radiation
YES

$200.00

100.00%
Reconstructive Surgery

1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality; 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required - please contact the number listed on your ID card.

YES

30.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Year

Limited to 30 combined visits per year (combined for occupational therapy, physical therapy and chiropractic care). Limited to 30 visits per year speech therapy. Limited to 30 visits per year cardiac therapy. Limited to 30 visits per year pulmonary therapy.

YES

$50.00

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Year

YES

$50.00

100.00%
Routine Dental Services (Adult)

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

YES

No Charge

100.00%
Routine Eye Exam (Adult)

Limit: 1.0 Exam(s) per Year

Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eye glasses.

YES

No Charge

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

No Charge

100.00%
Routine Foot Care
YES

$60.00

100.00%
Skilled Nursing Facility

Limit: 45.0 Days per Year

YES

30.00%

100.00%
Specialist Visit
YES

$60.00

100.00%
Specialty Drugs
YES

50.00%

100.00%
Substance Abuse Disorder Inpatient Services

Prior authorization may be required - please contact the number listed on your ID card.

YES

30.00%

100.00%
Substance Abuse Disorder Outpatient Services

Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization.

YES

$5.00

100.00%
Substance Use Disorder Emergency Room
YES

30.00%

30.00%
Substance Use Disorder Emergency Transportation/Ambulance

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

YES

30.00%

30.00%
Substance Use Disorder ER Physician Fee
YES

30.00%

30.00%
Substance Use Disorder Outpatient Other Services
YES

$200.00

100.00%
Substance Use Disorder Urgent Care
YES

$35.00

100.00%
Tier 1b Generic Drugs

Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information.

YES

$15.00

100.00%
Transplant

Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.

YES

30.00%

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), and Myofunctional therapy and surgery to the temporomandibular joint: such as condylectomy, meniscectomy, arthrotomy, and arthrocentesis.

YES

$200.00

100.00%
Urgent Care Centers or Facilities
YES

$35.00

100.00%
Weight Loss Programs

Weight loss programs under the supervision of a physician & obesity counseling.

YES

$60.00

100.00%
Well Baby Visits and Care

Covered in accordance with ACA guidelines.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$75.00

100.00%

Elite Gold + Vision + Adult Dental Health Insurance Plan Variant 58594MI0040023-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.82869979152411
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 Standard Gold Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 0.9602
First Tier Utilization 100%
Formulary ID MIF006
Formulary URL URL
HIOS Product ID 58594MI004
Import Date 2024-08-13 20:01:38
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 Yes
Is a Referral Required for Specialist? No
Issuer Actuarial Value 81.80%
Issuer ID 58594
Issuer Marketplace Marketing Name Ambetter from Meridian
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID MIN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan ID (Standard Component ID with Variant) 58594MI0040023-00
Plan Marketing Name Elite Gold + Vision + Adult Dental
Plan Type HMO
Plan Variant Marketing Name Elite Gold + Vision + Adult Dental
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,500
SBC Scenario, Having a Baby, Copayment $600
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 $1,100
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 $500
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID MIS001
Source Name SERFF
Plan ID 58594MI0040023
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 30.00%
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 $11000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $5500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $5,500
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 Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Elite Gold + Vision + Adult Dental Health Insurance Plan, 58594MI0040023

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Elite Gold + Vision + Adult Dental, 58594MI0040023 Health Insurance Plan, 58594MI0040023

  • Does Elite Gold + Vision + Adult Dental Health Insurance Plan, 58594MI0040023 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (58594MI0040023) Health Insurance Plan, Variant (58594MI0040023-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does (58594MI0040023) Health Insurance Plan, Variant (58594MI0040023-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (58594MI0040023) Health Insurance Plan, Variant (58594MI0040023-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

    Does (58594MI0040023) Health Insurance Plan, Variant (58594MI0040023-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does Elite Gold + Vision + Adult Dental Health Insurance Plan, Variant (58594MI0040023-00) offer Disease Management Programs for Asthma?

    Yes, the Elite Gold + Vision + Adult Dental Health Insurance Plan Variant 58594MI0040023-00 offers Disease Management Program for Asthma.

    Does Elite Gold + Vision + Adult Dental Health Insurance Plan, Variant (58594MI0040023-00) offer Disease Management Programs for Heart disease?

    Yes, the Elite Gold + Vision + Adult Dental Health Insurance Plan Variant 58594MI0040023-00 offers Disease Management Program for Heart disease.

    Does Elite Gold + Vision + Adult Dental Health Insurance Plan, Variant (58594MI0040023-00) offer Disease Management Programs for Diabetes?

    Yes, the Elite Gold + Vision + Adult Dental Health Insurance Plan Variant 58594MI0040023-00 offers Disease Management Program for Diabetes.

    Does Elite Gold + Vision + Adult Dental Health Insurance Plan, Variant (58594MI0040023-00) offer Disease Management Programs for Pregnancy?

    Yes, the Elite Gold + Vision + Adult Dental Health Insurance Plan Variant 58594MI0040023-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 17 Dec 2024 06:12 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