MyPriority Enhanced Gold Corewell Health West Michigan Network - 29698MI0540595 Health Insurance Plan
Priority Health health insurance plan with the Plan ID 29698MI0540595. The plan is called MyPriority Enhanced Gold Corewell Health West Michigan Network.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 80.10% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.90% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.86% (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 18.14% 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 | 29698MI0540595 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Priority Health | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 29698MI0540595-03 | ||||||||||||||||||
| Provider Network(s) | NONPREFERRED COREWELL-WEST-NARROW-HMO | ||||||||||||||||||
| 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 - 29698MI0540595-00 Standard On Exchange Plan - 29698MI0540595-01 |
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| Last Plan Update Date | Tue, 13 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of MyPriority Enhanced Gold Corewell Health West Michigan Network Health Insurance Plan, 29698MI0540595-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
NO | ||
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $250.00 |
100.00% |
| Applied Behavior Analysis Based Therapies
Only covered in relation to Autism Spectrum Disorder. |
YES | $45.00 |
100.00% |
| Autism Spectrum Disorders
Only covered in relation to Autism Spectrum Disorder. |
YES | $45.00 |
100.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime One procedure per lifetime. |
YES | 50.00% |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | $45.00 |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Maximum 30 visits per member per year. |
YES | $45.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | $1,000.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | $45.00 |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% |
100.00% |
| Emergency Room Services
|
YES | $250.00 |
$250.00 |
| Emergency Transportation/Ambulance
|
YES | $250.00 |
$250.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year One select eyeglass frame and one set of lenses, or provider designated contact lenses in lieu of eyeglass frames and lenses, per year. |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | $45.00 |
100.00% |
| Generic Drugs
Refer to the drug list for quantity limits and other exclusions. |
YES | $5.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year Up to 60 visits per year: limited to 30 speech therapy visits and 30 occupational and physical therapy rehabilitation visits per member per year (non-Autism Spectrum Disorder). See SBC for details. |
YES | $45.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Including hospice care in the home. |
YES | $45.00 |
100.00% |
| Hospice Services
|
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $250.00 |
100.00% |
| Infertility Treatment
Limits and exclusions apply. Diagnosis and treatment of underlying cause only. See SBC document. |
YES | 50.00% |
100.00% |
| Infusion Therapy
|
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $1000.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $45.00 |
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 | $1000.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $20.00 |
100.00% |
| Non-Preferred Brand Drugs
Refer to the drug list for quantity limits and other exclusions. |
YES | $100.00 |
100.00% |
| Nutritional Counseling
Dietician Services. |
YES | No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $45.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $1,000.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 90.0 Visit(s) per Year Up to 90 visits per year: limited to 30 speech therapy visits, 30 occupational and physical therapy, and 30 cardiac and pulmonary rehabilitation visits per member per year. See SBC for details. |
YES | $45.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge |
100.00% |
| Preferred Brand Drugs
Refer to the drug list for quantity limits and other exclusions. |
YES | $75.00 |
100.00% |
| Prenatal and Postnatal Care
Routine care is covered as preventive. Complications of Pregnancy is diagnostic/medical care will be covered as indicated by the SBC document. |
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
This plan includes one annual physical/wellness exam at no cost to the member. See plan documentation for available $10 virtual care cost share. |
YES | $20.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 50.00% |
100.00% |
| Radiation
|
YES | $45.00 |
100.00% |
| Reconstructive Surgery
|
YES | 50.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Combined maximum of 30 visits per year. |
YES | $45.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Maximum of 30 visits per year. |
YES | $45.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year One exam per year. See SBC for details. |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 45.0 Days per Year Up to 45 days per benefit period. This limit is combined with hospice facility, subacute facility, and inpatient rehabilitation care facility services. |
YES | $1000.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $45.00 |
100.00% |
| Specialty Drugs
Refer to the drug list for quantity limits and other exclusions. |
YES | 50.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $1000.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $0.00 |
100.00% |
| Transplant
|
YES | 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 | 50.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $75.00 |
100.00% |
| Weight Loss Programs
|
YES | $45.00 |
100.00% |
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $45.00 |
100.00% |
MyPriority Enhanced Gold Corewell Health West Michigan Network Health Insurance Plan Variant 29698MI0540595-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.818636121065904 |
| 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 | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | MIF009 |
| Formulary URL | URL |
| HIOS Product ID | 29698MI054 |
| Import Date | 2024-08-13 20:01:38 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 5 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 80.10% |
| Issuer ID | 29698 |
| Issuer Marketplace Marketing Name | Priority Health |
| 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 | MIN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Care Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Urgent/Emergency Care Only |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 29698MI0540595-03 |
| Plan Marketing Name | MyPriority Enhanced Gold Corewell Health West Michigan Network |
| Plan Type | HMO |
| Plan Variant Marketing Name | MyPriority Enhanced Gold Corewell Health West Michigan Network |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $2,900 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $400 |
| SBC Scenario, Having Diabetes, Copayment | $1,500 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MIS004 |
| Source Name | SERFF |
| Plan ID | 29698MI0540595 |
| 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 | $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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of MyPriority Enhanced Gold Corewell Health West Michigan Network Health Insurance Plan, 29698MI0540595
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about MyPriority Enhanced Gold Corewell Health West Michigan Network, 29698MI0540595 Health Insurance Plan, 29698MI0540595
-
Does MyPriority Enhanced Gold Corewell Health West Michigan Network Health Insurance Plan, 29698MI0540595 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (29698MI0540595) Health Insurance Plan, Variant (29698MI0540595-03) offer Disease Management Programs?
Does (29698MI0540595) Health Insurance Plan, Variant (29698MI0540595-03) have Out Of Country Coverage?
Does (29698MI0540595) Health Insurance Plan, Variant (29698MI0540595-03) have Out of Service Area Coverage?
Does (29698MI0540595) Health Insurance Plan, Variant (29698MI0540595-03) offer Disease Management Programs?
Does MyPriority Enhanced Gold Corewell Health West Michigan Network Health Insurance Plan, Variant (29698MI0540595-03) offer Disease Management Programs for Asthma?
Does MyPriority Enhanced Gold Corewell Health West Michigan Network Health Insurance Plan, Variant (29698MI0540595-03) offer Disease Management Programs for Heart disease?
Does MyPriority Enhanced Gold Corewell Health West Michigan Network Health Insurance Plan, Variant (29698MI0540595-03) offer Disease Management Programs for Depression?
Does MyPriority Enhanced Gold Corewell Health West Michigan Network Health Insurance Plan, Variant (29698MI0540595-03) offer Disease Management Programs for Diabetes?
Does MyPriority Enhanced Gold Corewell Health West Michigan Network Health Insurance Plan, Variant (29698MI0540595-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does MyPriority Enhanced Gold Corewell Health West Michigan Network Health Insurance Plan, Variant (29698MI0540595-03) offer Disease Management Programs for Low back pain?
Does MyPriority Enhanced Gold Corewell Health West Michigan Network Health Insurance Plan, Variant (29698MI0540595-03) offer Disease Management Programs for Pregnancy?
Does MyPriority Enhanced Gold Corewell Health West Michigan Network Health Insurance Plan, Variant (29698MI0540595-03) offer Disease Management Programs for Weight loss programs?
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