MHP Gold - 74917MI0020006 Health Insurance Plan
McLaren Health Plan Community health insurance plan with the Plan ID 74917MI0020006. The plan is called MHP Gold.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 74917MI0020006 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | McLaren Health Plan Community | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Health Insurance Plan Variant | 74917MI0020006-02 | ||||||||||||||||||
| Provider Network(s) | REWARDS OUT-OF-NETWORK IN-NETWORK | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 74917MI0020006-00 Standard On Exchange Plan - 74917MI0020006-01 |
||||||||||||||||||
| Last Plan Update Date | Sat, 12 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of MHP Gold Health Insurance Plan, 74917MI0020006-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
NO | ||
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $0.00, 0.00% |
100.00% |
| Applied Behavior Analysis Based Therapies
|
YES | $0.00, 0.00% |
100.00% |
| Autism Spectrum Disorders
Only covered in relation to Autism Spectrum Disorder. |
YES | $0.00, 0.00% |
100.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime |
YES | $0.00, 0.00% |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | $0.00, 0.00% |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Limit combined with OT and PT. |
YES | $0.00, 0.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | $0.00, 0.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $0.00, 0.00% |
100.00% |
| Dialysis
|
YES | $0.00, 0.00% |
100.00% |
| Durable Medical Equipment
|
YES | $0.00, 0.00% |
100.00% |
| Emergency Room Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
|
YES | $0.00, 0.00% |
0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
|
YES | $0.00, 0.00% |
100.00% |
| Generic Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Yearly limits: PT and OT: 30 visits, Speech: 30 visits. |
YES | $0.00, 0.00% |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | $0.00, 0.00% |
100.00% |
| Hospice Services
Coverage includes inpatient and outpatient hospice care. |
YES | $0.00, 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $0.00, 0.00% |
100.00% |
| Infertility Treatment
Underlying causes only. |
YES | $0.00, 0.00% |
100.00% |
| Infusion Therapy
|
YES | $0.00, 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $0.00, 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $0.00, 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Nutritional Counseling
Limit: 6.0 Visit(s) per Year Dietician Services. |
YES | $0.00, 0.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00, 0.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $0.00, 0.00% |
100.00% |
| Preferred Brand Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Prenatal and Postnatal Care
|
YES | $0.00, 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | $0.00, 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $0.00, 0.00% |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | $0.00, 0.00% |
100.00% |
| Radiation
|
YES | $0.00, 0.00% |
100.00% |
| Reconstructive Surgery
|
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Combined with chiro. |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 45.0 Days per Year |
YES | $0.00, 0.00% |
100.00% |
| Specialist Visit
|
YES | $0.00, 0.00% |
100.00% |
| Specialty Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Transplant
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $0.00, 0.00% |
$0.00 |
| Weight Loss Programs
|
YES | $0.00, 0.00% |
100.00% |
| Well Baby Visits and Care
|
YES | $0.00, 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $0.00, 0.00% |
100.00% |
MHP Gold Health Insurance Plan Variant 74917MI0020006-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| 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 | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 0.9994 |
| First Tier Utilization | 100% |
| Formulary ID | MIF011 |
| Formulary URL | URL |
| HIOS Product ID | 74917MI002 |
| Import Date | 2024-10-12 20:01:46 |
| 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 | 74917 |
| Issuer Marketplace Marketing Name | McLaren Health Plan Community |
| 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 | Yes |
| Out of Country Coverage Description | Emergency only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency only |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 74917MI0020006-02 |
| Plan Level Exclusions | No |
| Plan Marketing Name | MHP Gold |
| Plan Type | HMO |
| Plan Variant Marketing Name | MHP Gold |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| 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 | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MIS001 |
| Source Name | SERFF |
| Plan ID | 74917MI0020006 |
| 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 | 0.00% |
| 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 | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| 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 Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of MHP Gold Health Insurance Plan, 74917MI0020006
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about MHP Gold, 74917MI0020006 Health Insurance Plan, 74917MI0020006
-
Does MHP Gold Health Insurance Plan, 74917MI0020006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (74917MI0020006) Health Insurance Plan, Variant (74917MI0020006-02) have Out Of Country Coverage?
Does (74917MI0020006) Health Insurance Plan, Variant (74917MI0020006-02) have Out of Service Area Coverage?
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