MercyCare HMO Silver Standard - 54322IL0090011 Health Insurance Plan
MercyCare HMO, Inc. health insurance plan with the Plan ID 54322IL0090011. The plan is called MercyCare HMO Silver Standard.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.06% (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 5.94% 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 | 54322IL0090011 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 54322IL0090011-06 | ||||||||||||||||||
| 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 - 54322IL0090011-00 Standard On Exchange Plan - 54322IL0090011-01 Open to Indians below 300% FPL - 54322IL0090011-02 Open to Indians above 300% FPL - 54322IL0090011-03 73% AV Silver Plan - 54322IL0090011-04 |
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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 Standard Health Insurance Plan, 54322IL0090011-06
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | 25.00% |
100.00% |
| Accidental Dental
|
YES | 25.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 25.00% |
100.00% |
| Amino Acid-Based Elemental Formulas
|
YES | 25.00% |
100.00% |
| Autism Spectrum Disorders
|
YES | $0.00 |
100.00% |
| Bariatric Surgery
|
YES | 25.00% |
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 | 25.00% |
100.00% |
| Chemotherapy
|
YES | 25.00% |
100.00% |
| Chiropractic Care
Limit: 25.0 Visit(s) per Benefit Period |
YES | $0.00 |
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 | 25.00% |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% |
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 | 25.00% |
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 Benefit Period |
YES | 25.00% |
100.00% |
| Gender Affirming Care
|
YES | 25.00% |
100.00% |
| Generic Drugs
|
YES | $0.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Benefit Period Treatment must be medically necessary and therapeutic and not investigational. |
YES | 25.00% |
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 | 25.00% |
100.00% |
| Home Health Care Services
|
YES | 25.00% |
100.00% |
| Hospice Services
|
YES | 25.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Benefit provided for outpatient services and when these services are related to surgery or medical. |
YES | 25.00% |
100.00% |
| Infertility Treatment
Limitations vary based on procedures. |
YES | 25.00% |
100.00% |
| 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
Benefit provided for outpatient services and when these services are related to surgery or medical care. |
YES | 25.00% |
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 | 25.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $0.00 |
100.00% |
| Multiple Sclerosis Preventative Physical Therapy
|
YES | $0.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $50.00 |
100.00% |
| Nutritional Counseling
|
YES | $10.00 |
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 | $0.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% |
100.00% |
| Outpatient Rehabilitation Services
Maintenance therapies not covered. |
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
|
YES | $0.00 |
100.00% |
| Private-Duty Nursing
Outpatient coverage only |
YES | 25.00% |
100.00% |
| Prosthetic Devices
|
YES | 25.00% |
100.00% |
| Radiation
|
YES | 25.00% |
100.00% |
| Reconstructive Surgery
Only includes benefits for mastectomy-related services. |
YES | 25.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Benefit Period Maintenance Speech Therapy is not covered. |
YES | $0.00 |
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 | $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 Benefit Period |
YES | $10.00 |
100.00% |
| Routine Foot Care
Only covered for persons diagnosed with diabetes. |
YES | 25.00% |
100.00% |
| Skilled Nursing Facility
|
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
Benefit provided for outpatient services and when these services are related to surgery or medical care. |
YES | 25.00% |
100.00% |
MercyCare HMO Silver Standard Health Insurance Plan Variant 54322IL0090011-06 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.940590976666282 |
| 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 | 94% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| 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 | ILF004 |
| 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) | 54322IL0090011-06 |
| Plan Marketing Name | MercyCare HMO Silver Standard |
| Plan Type | HMO |
| Plan Variant Marketing Name | MercyCare HMO Silver Standard |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,800 |
| 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 | $200 |
| SBC Scenario, Having Diabetes, Copayment | $200 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $30 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ILS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All |
| Plan ID | 54322IL0090011 |
| 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 | 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 | $3600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $1800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $1,800 |
| 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 | No |
Copay & Coinsurance of MercyCare HMO Silver Standard Health Insurance Plan, 54322IL0090011
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about MercyCare HMO Silver Standard, 54322IL0090011 Health Insurance Plan, 54322IL0090011
-
Does MercyCare HMO Silver Standard Health Insurance Plan, 54322IL0090011 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (54322IL0090011) Health Insurance Plan, Variant (54322IL0090011-06) offer Disease Management Programs?
Does (54322IL0090011) Health Insurance Plan, Variant (54322IL0090011-06) have Out Of Country Coverage?
Does (54322IL0090011) Health Insurance Plan, Variant (54322IL0090011-06) have Out of Service Area Coverage?
Does (54322IL0090011) Health Insurance Plan, Variant (54322IL0090011-06) offer Disease Management Programs?
Does MercyCare HMO Silver Standard Health Insurance Plan, Variant (54322IL0090011-06) offer Disease Management Programs for Heart disease?
Does MercyCare HMO Silver Standard Health Insurance Plan, Variant (54322IL0090011-06) offer Disease Management Programs for Diabetes?
Does MercyCare HMO Silver Standard Health Insurance Plan, Variant (54322IL0090011-06) 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