Freedom Silver 4000 - 14624MS0010004 Health Insurance Plan
Primewell Health Services of Mississippi, Inc. health insurance plan with the Plan ID 14624MS0010004. The plan is called Freedom Silver 4000.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.12% (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 29.88% 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 | 14624MS0010004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Mississippi | ||||||||||||||||||
| Health Insurance Issuer | Primewell Health Services of Mississippi, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 14624MS0010004-01 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| 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 - 14624MS0010004-00 Standard On Exchange Plan - 14624MS0010004-01 Open to Indians below 300% FPL - 14624MS0010004-02 Open to Indians above 300% FPL - 14624MS0010004-03 73% AV Silver Plan - 14624MS0010004-04 |
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| Last Plan Update Date | Sat, 31 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Freedom Silver 4000 Health Insurance Plan, 14624MS0010004-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care. |
YES | 0.00% |
0.00% |
| Basic Dental Care - Child
|
YES | 50.00% |
50.00% |
| Chemotherapy
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Must be medically necessary. A treatment plan outlining goals of therapy, mode of therapy and duration of therapy must be submitted to Company by the provider prior to the initiation of treatment. The 20 visit limit is combined for chiropractic services, occupational therapy, and physical therapy. |
YES | $75.00 |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Minimum stay of 48 hours; no charge for professional services |
YES | $4500.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year |
YES | No Charge |
No Charge |
| Diabetes Education
|
YES | $40.00 |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
Various limitations apply |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
The ER Copay is waived if the visit results in an inpatient admission. |
YES | $550.00 Copay after deductible |
$550.00 Copay after deductible |
| Emergency Transportation/Ambulance
Air ambulance services are covered in only specified situations. |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | 50.00% |
50.00% Coinsurance after deductible |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Quantity limits, authorizations and step therapy limits may apply. |
YES | $20.00 |
100.00% |
| Habilitation Services
Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | $40.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Hearing Aids
|
NO | ||
| Home Health Care Services
May be available through the Care Management Program when provided by a network provider and prior authorization is received. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Limit: 6.0 Months per Lifetime Subject to Care Management. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $300.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | $300.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
Copays, if applicable, are per day for first three days only. |
YES | $1500.00 Copay per Day after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
Lab services in the Emergency Room are subject to the deductible, if applicable. |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care. |
YES | 0.00% |
0.00% |
| Major Dental Care - Child
|
YES | 50.00% |
50.00% |
| Mental/Behavioral Health Inpatient Services
Inpatient treatment for mental/behavioral health disorders must be Authorized |
YES | $1500.00 Copay per Day after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | $40.00 |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
Quantity limits, authorizations and step therapy limits may apply. |
YES | $100.00 Copay after deductible |
100.00% |
| Nutritional Counseling
Limit: 4.0 Visit(s) per Year Coverage only for diabetes education. |
YES | $40.00 |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Medically Necessary orthodontia only. |
YES | 50.00% |
50.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Quantitative limits depend on the type of visit. |
YES | $40.00 |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $1000.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 36.0 Visit(s) per Year Benefits available for outpatient cardiac rehabilitation. |
YES | $40.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
Quantity limits, authorizations and step therapy limits may apply. |
YES | $60.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | $40.00 |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
Covered services must be included in Grade A and B Recommendations of the USPSTF and include all other preventive health services required by PPACA. |
YES | No Charge |
50.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $40.00 |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Various limitations apply as stated in the Benchmark plan. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
Must be medically necessary. Company may require a treatment plan, outlining the goals of therapy, mode of therapy, and duration of therapy, to be submitted by the provider prior to the initiation of treatment. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
Plan only outlines benefits for breast reconstruction. Must be medically necessary and related to mastectomy. |
YES | $4500.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year The 20 visit limit is combined for chiropractic services, occupational therapy, and physical therapy. |
YES | $40.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Not covered for learning disabilities and development problems. |
YES | $40.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year Covers exam and cleaning |
YES | No Charge |
No Charge |
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Year An added benefit |
YES | $75.00 |
50.00% Coinsurance after deductible |
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | $75.00 |
50.00% Coinsurance after deductible |
| Routine Foot Care
Limit: 1.0 Visit(s) per Year Requires a Diabetes diagnosis. |
YES | No Charge |
50.00% |
| Skilled Nursing Facility
Limit: 30.0 Days per Benefit Period Three-day prior inpatient stay |
YES | $150.00 Copay per Day after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $75.00 |
50.00% Coinsurance after deductible |
| Specialty Drugs
Specialty drugs may be limited to a thirty (30) day supply. Quantity limits, authorizations and step therapy limits may apply. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Inpatient treatment for substance abuse must be Authorized |
YES | $1500.00 Copay per Day after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | $40.00 |
50.00% Coinsurance after deductible |
| Transplant
Non-EHB and out-of-network transplant services not covered |
YES | $4500.00 Copay after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Medical necessity documentation and a treatment plan must be submitted to and approved by the Company prior to the commencement of treatment. Prior authorization is required. |
YES | $4500.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
|
YES | $75.00 |
50.00% Coinsurance after deductible |
| Weight Loss Programs
Exclusions: Non-Vantage Weight Loss programs are excluded. Vantage Weight Loss programs are covered as part of the Vantage Wellness Program. |
YES | No Charge |
100.00% |
| Well Baby Visits and Care
|
YES | No Charge |
50.00% |
| X-rays and Diagnostic Imaging
|
YES | $300.00 Copay after deductible |
50.00% Coinsurance after deductible |
Freedom Silver 4000 Health Insurance Plan Variant 14624MS0010004-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7012196012812262 |
| 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 Silver On Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1000 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $1,000 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Weight Loss Programs |
| EHB Percent of Total Premium | 0.97776179 |
| First Tier Utilization | 100% |
| Formulary ID | MSF001 |
| Formulary URL | URL |
| HIOS Product ID | 14624MS001 |
| Import Date | 2024-08-31 01:01:56 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 3 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 14624 |
| Issuer Marketplace Marketing Name | Primewell Health Services of Mississippi |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $12000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $4000 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $4,000 |
| Medical EHB Deductible, Out of Network, Family Per Group | $15000 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $5000 per person |
| Medical EHB Deductible, Out of Network, Individual | $5,000 |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MSN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Limited to Emergency Services only. Covered as in-network. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Out-of-Network Deductible and Co-insurance |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 14624MS0010004-01 |
| Plan Marketing Name | Freedom Silver 4000 |
| Plan Type | POS |
| Plan Variant Marketing Name | Freedom Silver 4000 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,500 |
| SBC Scenario, Having a Baby, Deductible | $4,000 |
| 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 | $1,800 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,900 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MSS001 |
| Source Name | HIOS |
| Plan ID | 14624MS0010004 |
| State Code | MS |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| 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 | Yes |
Copay & Coinsurance of Freedom Silver 4000 Health Insurance Plan, 14624MS0010004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Freedom Silver 4000, 14624MS0010004 Health Insurance Plan, 14624MS0010004
-
Does Freedom Silver 4000 Health Insurance Plan, 14624MS0010004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (14624MS0010004) Health Insurance Plan, Variant (14624MS0010004-01) offer Disease Management Programs?
Does (14624MS0010004) Health Insurance Plan, Variant (14624MS0010004-01) have Out Of Country Coverage?
Does (14624MS0010004) Health Insurance Plan, Variant (14624MS0010004-01) have Out of Service Area Coverage?
Does (14624MS0010004) Health Insurance Plan, Variant (14624MS0010004-01) offer Disease Management Programs?
Does Freedom Silver 4000 Health Insurance Plan, Variant (14624MS0010004-01) offer Disease Management Programs for Heart disease?
Does Freedom Silver 4000 Health Insurance Plan, Variant (14624MS0010004-01) offer Disease Management Programs for Depression?
Does Freedom Silver 4000 Health Insurance Plan, Variant (14624MS0010004-01) offer Disease Management Programs for Diabetes?
Does Freedom Silver 4000 Health Insurance Plan, Variant (14624MS0010004-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Freedom Silver 4000 Health Insurance Plan, Variant (14624MS0010004-01) offer Disease Management Programs for Weight loss programs?
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