MercyCare Silver 2500 (3 Free PCP Visits) - 54322IL0090004 Health Insurance Plan
MercyCare HMO, Inc. health insurance plan with the Plan ID 54322IL0090004. The plan is called MercyCare Silver 2500 (3 Free PCP Visits).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.22% (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 28.78% 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 | 54322IL0090004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Illinois | ||||||||||||||||||
| Health Insurance Issuer | MercyCare HMO, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 54322IL0090004-00 | ||||||||||||||||||
| 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 - 54322IL0090004-00 Standard On Exchange Plan - 54322IL0090004-01 Open to Indians below 300% FPL - 54322IL0090004-02 Open to Indians above 300% FPL - 54322IL0090004-03 73% AV Silver Plan - 54322IL0090004-04 |
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| Last Plan Update Date | Wed, 14 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of MercyCare Silver 2500 (3 Free PCP Visits) Health Insurance Plan, 54322IL0090004-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Accidental Dental
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Amino Acid-Based Elemental Formulas
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Autism Spectrum Disorders
|
YES | $50.00 |
100.00% |
| Bariatric Surgery
|
YES | 50.00% Coinsurance 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 |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 25.0 Visit(s) per Benefit Period |
YES | $50.00 |
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 | 50.00% Coinsurance after deductible |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% Coinsurance 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 | 50.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
|
YES | $20.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Benefit Period Treatment must be medically necessary and therapeutic and not investigational. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Limit: 2.0 Visit(s) per 3 Years Benefits are for bone anchored hearing aids. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Benefit provided for inpatient and outpatient services and when these services are related to surgery or medical. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Limitations vary based on procedures. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 50.00% Coinsurance 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 | 50.00% Coinsurance 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 | 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $50.00 |
100.00% |
| Multiple Sclerosis Preventative Physical Therapy
|
YES | $50.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $100.00 |
100.00% |
| Nutritional Counseling
|
YES | $100.00 |
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 | $50.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Maintenance therapies not covered. |
YES | $50.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $50.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $50.00 |
100.00% |
| Private-Duty Nursing
Outpatient coverage only |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Only includes benefits for mastectomy-related services, and medically necessary services intended to restore physical appearance with prior authorization. |
YES | 50.00% Coinsurance 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 | $50.00 |
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 intellectual disability, except as may be provided under this Certificate for Autism Spectrum Disorder(s). |
YES | $50.00 |
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 | $100.00 |
100.00% |
| Routine Foot Care
Only covered for persons diagnosed with diabetes. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Skilled Nursing Facility
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $100.00 |
100.00% |
| Specialty Drugs
|
YES | $500.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $50.00 |
100.00% |
| Transplant
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $100.00 |
$100.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Benefit provided for inpatient and outpatient services and when these services are related to surgery or medical care. |
YES | 50.00% Coinsurance after deductible |
100.00% |
MercyCare Silver 2500 (3 Free PCP Visits) Health Insurance Plan Variant 54322IL0090004-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.712179192654731 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
| 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 Off 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 | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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, Diabetes, High Blood Pressure & High Cholesterol |
| EHB Percent of Total Premium | 0.9969 |
| First Tier Utilization | 100% |
| Formulary ID | ILF003 |
| Formulary URL | URL |
| HIOS Product ID | 54322IL009 |
| Import Date | 2024-08-14 20:01:41 |
| 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 | 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 | 50.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $5000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $2500 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $2,500 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| 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 | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 54322IL0090004-00 |
| Plan Marketing Name | MercyCare Silver 2500 (3 Free PCP Visits) |
| Plan Type | HMO |
| Plan Variant Marketing Name | MercyCare Silver 2500 (3 Free PCP Visits) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $5,000 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $2,500 |
| 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 | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,100 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ILS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All |
| Plan ID | 54322IL0090004 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| 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 Silver 2500 (3 Free PCP Visits) Health Insurance Plan, 54322IL0090004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about MercyCare Silver 2500 (3 Free PCP Visits), 54322IL0090004 Health Insurance Plan, 54322IL0090004
-
Does MercyCare Silver 2500 (3 Free PCP Visits) Health Insurance Plan, 54322IL0090004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (54322IL0090004) Health Insurance Plan, Variant (54322IL0090004-00) offer Disease Management Programs?
Does (54322IL0090004) Health Insurance Plan, Variant (54322IL0090004-00) have Out Of Country Coverage?
Does (54322IL0090004) Health Insurance Plan, Variant (54322IL0090004-00) have Out of Service Area Coverage?
Does (54322IL0090004) Health Insurance Plan, Variant (54322IL0090004-00) offer Disease Management Programs?
Does MercyCare Silver 2500 (3 Free PCP Visits) Health Insurance Plan, Variant (54322IL0090004-00) offer Disease Management Programs for Heart disease?
Does MercyCare Silver 2500 (3 Free PCP Visits) Health Insurance Plan, Variant (54322IL0090004-00) offer Disease Management Programs for Diabetes?
Does MercyCare Silver 2500 (3 Free PCP Visits) Health Insurance Plan, Variant (54322IL0090004-00) offer Disease Management Programs for High blood pressure & high cholesterol?
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