Gold 1 with Adult Vision Services - 40047MI0080001 Health Insurance Plan
Molina Healthcare of Michigan, Inc. health insurance plan with the Plan ID 40047MI0080001. The plan is called Gold 1 with Adult Vision Services.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.36% (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 21.64% 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 | 40047MI0080001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Molina Healthcare of Michigan, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 40047MI0080001-03 | ||||||||||||||||||
| Provider Network(s) | ['MIN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 40047MI0080001-00 Standard On Exchange Plan - 40047MI0080001-01 |
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| Last Plan Update Date | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 24 Dec 2024 06:21 GMT |
Benefits of Gold 1 with Adult Vision Services Health Insurance Plan, 40047MI0080001-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $20.00 |
100.00% |
| Autism Spectrum Disorders
|
YES | $20.00 |
100.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime Cost sharing listed matches Inpatient Physician and Surgical Services cost share, which is typical for most enrollees. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 30.00% 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 | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | $50.00 |
100.00% |
| Durable Medical Equipment
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
Cost sharing listed matches Inpatient Physician and Surgical Services cost share, which is typical for most enrollees. |
NO | ||
| Generic Drugs
|
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Yearly limits: PT and OT: 30 visits, Speech: 30 visits. |
YES | $20.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | No Charge |
100.00% |
| Hospice Services
Limit: 45.0 Days per Year Coverage includes inpatient and outpatient hospice care. Limitation applies to facility-based care only. Home-based hospice care has no quanitative limit. |
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Underlying causes only. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
Cost sharing listed matches Outpatient Surgery Physician/Surgical Services cost share, which is typical for most enrollees |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $15.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $20.00 |
100.00% |
| Mental Behavioral Health Outpatient Services - Other
Cost sharing listed matches Outpatient Facility Fee (e.g., Ambulatory Surgery Center) and Outpatient Surgery Phsycian/Surgical Services. |
YES | 25.00% Coinsurance after deductible |
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 | No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $20.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% 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 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $50.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $20.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Combined with chiro. |
YES | $20.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year |
YES | $20.00 |
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 | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 45.0 Days per Year |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $50.00 |
100.00% |
| Specialty Drugs
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
YES | $20.00 |
100.00% |
| Substance Use Disorder Outpatient Services - Other
Cost sharing listed matches Outpatient Facility Fee (e.g., Ambulatory Surgery Center) and Outpatient Surgery Phsycian/Surgical Services. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Transplant
Cost sharing listed matches Inpatient Physician and Surgical Services cost share, which is typical for most enrollees. |
YES | 25.00% 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 | 25.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $20.00 |
100.00% |
| Weight Loss Programs
|
YES | No Charge |
100.00% |
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Gold 1 LCS with Adult Vision Services Health Insurance Plan Variant 40047MI0080001-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7836322822148821 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| 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 | Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.9877 |
| First Tier Utilization | 100% |
| Formulary ID | MIF001 |
| Formulary URL | URL |
| HIOS Product ID | 40047MI008 |
| Import Date | 2023-08-16 20:01:48 |
| 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 | 40047 |
| Issuer Marketplace Marketing Name | Molina Healthcare |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 40047MI0080001-03 |
| Plan Marketing Name | Gold 1 with Adult Vision Services |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold 1 LCS with Adult Vision Services |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,500 |
| SBC Scenario, Having a Baby, Copayment | $300 |
| SBC Scenario, Having a Baby, Deductible | $1,550 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $1,550 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $40 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,550 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MIS001 |
| Source Name | SERFF |
| Plan ID | 40047MI0080001 |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3100 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1550 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,550 |
| 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 | $16200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,100 |
| 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 Gold 1 with Adult Vision Services Health Insurance Plan, 40047MI0080001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold 1 with Adult Vision Services, 40047MI0080001 Health Insurance Plan, 40047MI0080001
-
Does Gold 1 with Adult Vision Services Health Insurance Plan, 40047MI0080001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (40047MI0080001) Health Insurance Plan, Variant (40047MI0080001-03) offer Disease Management Programs?
Does (40047MI0080001) Health Insurance Plan, Variant (40047MI0080001-03) have Out Of Country Coverage?
Does (40047MI0080001) Health Insurance Plan, Variant (40047MI0080001-03) have Out of Service Area Coverage?
Does (40047MI0080001) Health Insurance Plan, Variant (40047MI0080001-03) offer Disease Management Programs?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (40047MI0080001-03) offer Disease Management Programs for Asthma?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (40047MI0080001-03) offer Disease Management Programs for Heart disease?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (40047MI0080001-03) offer Disease Management Programs for Depression?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (40047MI0080001-03) offer Disease Management Programs for Diabetes?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (40047MI0080001-03) offer Disease Management Programs for Pregnancy?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (40047MI0080001-03) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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