MercyCare HMO Silver Option B - 54322IL0090006 Health Insurance Plan
MercyCare HMO, Inc. health insurance plan with the Plan ID 54322IL0090006. The plan is called MercyCare HMO Silver Option B.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.04% (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 28.96% 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 | 54322IL0090006 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Illinois | ||||||||||||||||||
| Health Insurance Issuer | MercyCare HMO, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 54322IL0090006-03 | ||||||||||||||||||
| 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 - 54322IL0090006-00 Standard On Exchange Plan - 54322IL0090006-01 Open to Indians below 300% FPL - 54322IL0090006-02 Open to Indians above 300% FPL - 54322IL0090006-03 73% AV Silver Plan - 54322IL0090006-04 |
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| Last Plan Update Date | Mon, 18 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of MercyCare HMO Silver Option B Health Insurance Plan, 54322IL0090006-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | No Charge after deductible |
100.00% |
| Accidental Dental
|
YES | No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
100.00% |
| Amino Acid-Based Elemental Formulas
|
YES | No Charge after deductible |
100.00% |
| Autism Spectrum Disorders
|
YES | No Charge after deductible |
100.00% |
| Bariatric Surgery
|
YES | No Charge after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Select State offered plan |
NO | ||
| Breast Implant Removal
Exclusions: Does not apply for implants implanted solely for cosmetic reasons |
YES | No Charge after deductible |
100.00% |
| Chemotherapy
|
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
Limit: 25.0 Visit(s) per Benefit Period |
YES | No Charge after deductible |
100.00% |
| Cosmetic Surgery
Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered. |
YES | No Charge after deductible |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
Select State offered plan |
NO | ||
| Diabetes Education
Services must be rendered by a physician, or duly certified, or licensed health care professional with expertise in diabetes management. |
YES | No Charge after deductible |
100.00% |
| Dialysis
|
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
|
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | No Charge after deductible |
100.00% |
| Gender Affirming Care
|
YES | No Charge after deductible |
100.00% |
| Generic Drugs
|
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Benefit Period Treatment must be medically necessary and therapeutic and not investigational. |
YES | No Charge after deductible |
100.00% |
| Hearing Aids
Limit: 2.0 Item(s) per 2 Years Benefits are for bone anchored hearing aids. Quantity limit applies to hearing aids for children. |
YES | No Charge after deductible |
100.00% |
| Home Health Care Services
|
YES | No Charge after deductible |
100.00% |
| Hospice Services
|
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Benefit provided for outpatient services and when these services are related to surgery or medical. |
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
Limitations vary based on procedures. |
YES | No Charge after deductible |
100.00% |
| Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Benefit provided for outpatient services and when these services are related to surgery or medical care. |
YES | No Charge after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Select State offered plan |
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | No Charge after deductible |
100.00% |
| Multiple Sclerosis Preventative Physical Therapy
|
YES | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
|
YES | No Charge after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Select State offered plan |
NO | ||
| Osteoporosis
|
YES | No Charge |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Rehabilitation Services
Maintenance therapies not covered. |
YES | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | No Charge after deductible |
100.00% |
| Private-Duty Nursing
Outpatient coverage only |
YES | No Charge after deductible |
100.00% |
| Prosthetic Devices
|
YES | No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
Only includes benefits for mastectomy-related services. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Benefit Period Maintenance Speech Therapy is not covered. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Benefit Period When rendered for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome) attention disorder, conceptual handicap or mental retardation, except as may be provided under this Certificate for Autism Spectrum Disorder(s). |
YES | No Charge after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period |
YES | No Charge after deductible |
100.00% |
| Routine Foot Care
Only covered for persons diagnosed with diabetes. |
YES | No Charge after deductible |
100.00% |
| Skilled Nursing Facility
|
YES | No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | No Charge after deductible |
100.00% |
| Specialty Drugs
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible |
100.00% |
| Transplant
|
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
No Charge after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Benefit provided for outpatient services and when these services are related to surgery or medical care. |
YES | No Charge after deductible |
100.00% |
MercyCare HMO Silver Option B Health Insurance Plan Variant 54322IL0090006-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.710371456207679 |
| 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 | Heart Disease, Diabetes, High Blood Pressure & High Cholesterol |
| EHB Percent of Total Premium | 0.9969 |
| First Tier Utilization | 100% |
| Formulary ID | ILF002 |
| Formulary URL | URL |
| HIOS Product ID | 54322IL009 |
| Import Date | 2023-12-18 20:02:01 |
| 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? | Yes |
| Issuer ID | 54322 |
| Issuer Marketplace Marketing Name | MercyCare Health Plans |
| 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 | ILN001 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Limited to emergency services only |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Limited to emergency services only |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 54322IL0090006-03 |
| Plan Marketing Name | MercyCare HMO Silver Option B |
| Plan Type | HMO |
| Plan Variant Marketing Name | MercyCare HMO Silver Option B |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $5,400 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,400 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ILS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All |
| Plan ID | 54322IL0090006 |
| State Code | IL |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $10800 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5400 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,400 |
| 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 | $10800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,400 |
| 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 MercyCare HMO Silver Option B Health Insurance Plan, 54322IL0090006
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about MercyCare HMO Silver Option B, 54322IL0090006 Health Insurance Plan, 54322IL0090006
-
Does MercyCare HMO Silver Option B Health Insurance Plan, 54322IL0090006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (54322IL0090006) Health Insurance Plan, Variant (54322IL0090006-03) offer Disease Management Programs?
Does (54322IL0090006) Health Insurance Plan, Variant (54322IL0090006-03) have Out Of Country Coverage?
Does (54322IL0090006) Health Insurance Plan, Variant (54322IL0090006-03) have Out of Service Area Coverage?
Does (54322IL0090006) Health Insurance Plan, Variant (54322IL0090006-03) offer Disease Management Programs?
Does MercyCare HMO Silver Option B Health Insurance Plan, Variant (54322IL0090006-03) offer Disease Management Programs for Heart disease?
Does MercyCare HMO Silver Option B Health Insurance Plan, Variant (54322IL0090006-03) offer Disease Management Programs for Diabetes?
Does MercyCare HMO Silver Option B Health Insurance Plan, Variant (54322IL0090006-03) offer Disease Management Programs for High blood pressure & high cholesterol?
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