MHP Silver Exchange Rewards - 74917MI0020017 Health Insurance Plan
McLaren Health Plan Community health insurance plan with the Plan ID 74917MI0020017. The plan is called MHP Silver Exchange Rewards.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.15% (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 12.85% 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 | 74917MI0020017 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | McLaren Health Plan Community | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Health Insurance Plan Variant | 74917MI0020017-05 | ||||||||||||||||||
| 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). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 74917MI0020017-00 Standard On Exchange Plan - 74917MI0020017-01 Open to Indians below 300% FPL - 74917MI0020017-02 Open to Indians above 300% FPL - 74917MI0020017-03 73% AV Silver Plan - 74917MI0020017-04 |
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| Last Plan Update Date | Sat, 12 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of MHP Silver Exchange Rewards Health Insurance Plan, 74917MI0020017-05
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
NO | ||
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Applied Behavior Analysis Based Therapies
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Autism Spectrum Disorders
Only covered in relation to Autism Spectrum Disorder. |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Limit combined with OT and PT. |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Dialysis
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Gender Affirming Care
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
|
YES | Tier 1: $5.00 Tier 2: $5.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Yearly limits: PT and OT: 30 visits, Speech: 30 visits. |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Coverage includes inpatient and outpatient hospice care. |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Underlying causes only. |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
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 | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | Tier 1: 33.00% Tier 2: 33.00% |
100.00% |
| Nutritional Counseling
Limit: 6.0 Visit(s) per Year Dietician Services. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
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 | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | Tier 1: $45.00 Tier 2: $45.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Combined with chiro. |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 45.0 Days per Year |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Specialty Drugs
|
YES | Tier 1: 33.00% Tier 2: 33.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Transplant
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
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 | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Weight Loss Programs
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
| Well Baby Visits and Care
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 25.00% Coinsurance after deductible |
100.00% |
MHP Silver Exchange Rewards Health Insurance Plan Variant 74917MI0020017-05 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.87147547206837 |
| 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 | 87% AV Level Silver 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, In Network (Tier 2), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 2), 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 |
| EHB Percent of Total Premium | 0.9994 |
| First Tier Utilization | 36% |
| Formulary ID | MIF007 |
| 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 | 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 | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $1000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $500 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $500 |
| Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 25.00% |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $3000 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $1500 per person |
| Medical EHB Deductible, In Network (Tier 2), Individual | $1,500 |
| 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 | Yes |
| 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) | 74917MI0020017-05 |
| Plan Level Exclusions | No |
| Plan Marketing Name | MHP Silver Exchange Rewards |
| Plan Type | HMO |
| Plan Variant Marketing Name | MHP Silver Exchange Rewards |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,500 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $1,500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $10 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 64% |
| Service Area ID | MIS001 |
| Source Name | SERFF |
| Plan ID | 74917MI0020017 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $6000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $3000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $6000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $3000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $3,000 |
| 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 Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of MHP Silver Exchange Rewards Health Insurance Plan, 74917MI0020017
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about MHP Silver Exchange Rewards, 74917MI0020017 Health Insurance Plan, 74917MI0020017
-
Does MHP Silver Exchange Rewards Health Insurance Plan, 74917MI0020017 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (74917MI0020017) Health Insurance Plan, Variant (74917MI0020017-05) have Out Of Country Coverage?
Does (74917MI0020017) Health Insurance Plan, Variant (74917MI0020017-05) 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