Medica Insure Silver Standard - 20305NE0040057 Health Insurance Plan

Medica Insurance Company health insurance plan with the Plan ID 20305NE0040057. The plan is called Medica Insure Silver Standard.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.14% (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 5.86% 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 20305NE0040057
Health Insurance Plan Year 2025
State Nebraska
Health Insurance Issuer Medica Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 20305NE0040057-06
Provider Network(s) PREFERREDTIER PREFERRED STANDARDTIER
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT).

Providers Nebraska All US States
All 13589 114584
PCP 1744 9704
Allergy 4 25
OB/GYN 48 299
Dentists 6 29
Available Variants of the Health Plan

Standard Off Exchange Plan - 20305NE0040057-00

Standard On Exchange Plan - 20305NE0040057-01

Open to Indians below 300% FPL - 20305NE0040057-02

Open to Indians above 300% FPL - 20305NE0040057-03

73% AV Silver Plan - 20305NE0040057-04

87% AV Silver Plan - 20305NE0040057-05

94% AV Silver Plan - 20305NE0040057-06

Last Plan Update Date Thu, 15 Aug 2024 00:00 GMT
Last Import Date Tue, 03 Dec 2024 06:24 GMT

Benefits of Medica Insure Silver Standard Health Insurance Plan, 20305NE0040057-06

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

25.00%

100.00%
Acupuncture
NO
Allergy Testing
YES

25.00%

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

$10.00

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

YES

$0.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

25.00%

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

No Charge

100.00%
Dialysis
YES

25.00%

100.00%
Durable Medical Equipment
YES

25.00%

100.00%
Emergency Room Services
YES

25.00%

25.00%
Emergency Transportation/Ambulance
YES

25.00%

25.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

See policy or plan document for additional benefit explanation.

YES

25.00%

100.00%
Gender Affirming Care
YES

25.00%

100.00%
Generic Drugs
YES

$0.00

100.00%
Habilitation Services

Limit: 45.0 Treatment(s) per Year

See policy or plan document for additional benefit explanation.

YES

$0.00

100.00%
Hearing Aids

Limited to $3000 every 48 months age 18 and under.

YES

25.00%

100.00%
Home Health Care Services

Limit: 60.0 Days per Year

YES

25.00%

100.00%
Hospice Services
YES

25.00%

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

25.00%

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

25.00%

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

25.00%

100.00%
Inpatient Physician and Surgical Services
YES

25.00%

100.00%
Laboratory Outpatient and Professional Services
YES

25.00%

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

25.00%

100.00%
Mental/Behavioral Health Outpatient Services
YES

$0.00

100.00%
Non-Preferred Brand Drugs
YES

$50.00

100.00%
Nutritional Counseling

See policy or plan document for additional benefit explanation.

YES

25.00%

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$0.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

25.00%

100.00%
Outpatient Rehabilitation Services

Limit: 45.0 Treatment(s) per Year

See policy or plan document for additional benefit explanation.

YES

$0.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

25.00%

100.00%
Preferred Brand Drugs
YES

$15.00

100.00%
Prenatal and Postnatal Care
YES

25.00%

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness

Virtual visits are unlimited with a $0 copayment when provided by a designated in-network virtual care provider for non-urgent medical symptoms for common illnesses.

YES

$0.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

25.00%

100.00%
Radiation
YES

25.00%

100.00%
Reconstructive Surgery

See policy or plan document for additional benefit explanation.

YES

25.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 45.0 Visit(s) per Year

See policy or plan document for additional benefit explanation.

YES

$0.00

100.00%
Rehabilitative Speech Therapy

Limit: 45.0 Visit(s) per Year

See policy or plan document for additional benefit explanation.

YES

$0.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
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: 60.0 Days per Year

YES

25.00%

100.00%
Specialist Visit
YES

$10.00

100.00%
Specialty Drugs
YES

$150.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

25.00%

100.00%
Substance Abuse Disorder Outpatient Services
YES

$0.00

100.00%
Transplant
YES

25.00%

100.00%
Treatment for Temporomandibular Joint Disorders
YES

25.00%

100.00%
Urgent Care Centers or Facilities
YES

$5.00

$5.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

25.00%

100.00%

Medica Insure Silver Standard Health Insurance Plan Variant 20305NE0040057-06 Attributes

Plan Attribute Value
AV Calculator Output Number 0.9414114984395309
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 94% AV Level Silver Plan
Dental Only Plan No
Design Type Design 1
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 1.0
First Tier Utilization 100%
Formulary ID NEF002
Formulary URL URL
HIOS Product ID 20305NE004
Import Date 2024-08-15 20:01:43
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 20305
Issuer Marketplace Marketing Name Medica
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 NEN001
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Services
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Services
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 20305NE0040057-06
Plan Marketing Name Medica Insure Silver Standard
Plan Type EPO
Plan Variant Marketing Name Medica Insure Silver Standard
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,000
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $300
SBC Scenario, Having Diabetes, Copayment $500
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $600
SBC Scenario, Treatment of a Simple Fracture, Copayment $20
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID NES001
Source Name SERFF
Plan ID 20305NE0040057
State Code NE
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 $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 $4000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $2000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $2,000
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 Medica Insure Silver Standard Health Insurance Plan, 20305NE0040057

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

Frequently Asked Questions(FAQ) about Medica Insure Silver Standard, 20305NE0040057 Health Insurance Plan, 20305NE0040057

  • Does Medica Insure Silver Standard Health Insurance Plan, 20305NE0040057 support Mail Ordering?

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

  • Does (20305NE0040057) Health Insurance Plan, Variant (20305NE0040057-06) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does (20305NE0040057) Health Insurance Plan, Variant (20305NE0040057-06) have Out Of Country Coverage?

    Yes. Details: Emergency Services

    Does (20305NE0040057) Health Insurance Plan, Variant (20305NE0040057-06) have Out of Service Area Coverage?

    Yes. Details: Emergency Services

    Does (20305NE0040057) Health Insurance Plan, Variant (20305NE0040057-06) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does Medica Insure Silver Standard Health Insurance Plan, Variant (20305NE0040057-06) offer Disease Management Programs for Asthma?

    Yes, the Medica Insure Silver Standard Health Insurance Plan Variant 20305NE0040057-06 offers Disease Management Program for Asthma.

    Does Medica Insure Silver Standard Health Insurance Plan, Variant (20305NE0040057-06) offer Disease Management Programs for Heart disease?

    Yes, the Medica Insure Silver Standard Health Insurance Plan Variant 20305NE0040057-06 offers Disease Management Program for Heart disease.

    Does Medica Insure Silver Standard Health Insurance Plan, Variant (20305NE0040057-06) offer Disease Management Programs for Depression?

    Yes, the Medica Insure Silver Standard Health Insurance Plan Variant 20305NE0040057-06 offers Disease Management Program for Depression.

    Does Medica Insure Silver Standard Health Insurance Plan, Variant (20305NE0040057-06) offer Disease Management Programs for Diabetes?

    Yes, the Medica Insure Silver Standard Health Insurance Plan Variant 20305NE0040057-06 offers Disease Management Program for Diabetes.

    Does Medica Insure Silver Standard Health Insurance Plan, Variant (20305NE0040057-06) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Medica Insure Silver Standard Health Insurance Plan Variant 20305NE0040057-06 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Medica Insure Silver Standard Health Insurance Plan, Variant (20305NE0040057-06) offer Disease Management Programs for Low back pain?

    Yes, the Medica Insure Silver Standard Health Insurance Plan Variant 20305NE0040057-06 offers Disease Management Program for Low back pain.

    Does Medica Insure Silver Standard Health Insurance Plan, Variant (20305NE0040057-06) offer Disease Management Programs for Pregnancy?

    Yes, the Medica Insure Silver Standard Health Insurance Plan Variant 20305NE0040057-06 offers Disease Management Program for Pregnancy.

 

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