MyPriority Value Bronze HSA Southeast Michigan Network - 29698MI0540803 Health Insurance Plan
Priority Health health insurance plan with the Plan ID 29698MI0540803. The plan is called MyPriority Value Bronze HSA Southeast Michigan Network.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.61% (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 35.39% 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 | 29698MI0540803 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Priority Health | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 29698MI0540803-00 | ||||||||||||||||||
| Provider Network(s) | NONPREFERRED BEAUMONT-NARROW-NETWORK-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 - 29698MI0540803-00 Standard On Exchange Plan - 29698MI0540803-01 |
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| Last Plan Update Date | Mon, 20 Nov 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of MyPriority Value Bronze HSA Southeast Michigan Network Health Insurance Plan, 29698MI0540803-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
NO | ||
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
100.00% |
| Applied Behavior Analysis Based Therapies
Only covered in relation to Autism Spectrum Disorder. |
YES | No Charge after deductible |
100.00% |
| Autism Spectrum Disorders
Only covered in relation to Autism Spectrum Disorder. |
YES | No Charge after deductible |
100.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime One procedure per lifetime. |
YES | No Charge after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Maximum 30 visits per member per year combined with rehabilitative occupational and physical therapy. |
YES | No Charge after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
|
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
| 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 | No Charge after deductible |
100.00% |
| Generic Drugs
Refer to the drug list for quantity limits and other exclusions. |
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Including hospice care in the home. |
YES | No Charge after deductible |
100.00% |
| Hospice Services
|
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
Limits and exclusions apply. Diagnosis and treatment of underlying cause only. See SBC document. |
YES | No Charge after deductible |
100.00% |
| Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | No Charge 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 | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
Refer to the drug list for quantity limits and other exclusions. |
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
Limit: 6.0 Visit(s) per Year Maximum of six visits per year of nutritional counseling/dietician services. |
YES | No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
Refer to the drug list for quantity limits and other exclusions. |
YES | No Charge after deductible |
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. |
YES | No Charge after deductible |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
|
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Combined maximum of 30 visits per year. Combined with Chiropractic Care |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Maximum of 30 visits per year. |
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | No Charge after deductible |
100.00% |
| Specialty Drugs
Refer to the drug list for quantity limits and other exclusions. |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible |
100.00% |
| Transplant
|
YES | No Charge 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 | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
100.00% |
| Weight Loss Programs
|
YES | No Charge after deductible |
100.00% |
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
100.00% |
MyPriority Value Bronze HSA Southeast Michigan Network Health Insurance Plan Variant 29698MI0540803-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.646083378701239 |
| 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 | Standard Bronze Off Exchange Plan |
| 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 | MIF001 |
| Formulary URL | URL |
| HIOS Product ID | 29698MI054 |
| Import Date | 2023-11-20 20:02:00 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| 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 | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MIN004 |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 29698MI0540803-00 |
| Plan Marketing Name | MyPriority Value Bronze HSA Southeast Michigan Network |
| Plan Type | HMO |
| Plan Variant Marketing Name | MyPriority Value Bronze HSA Southeast Michigan Network |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,200 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,400 |
| 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 | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MIS006 |
| Source Name | SERFF |
| Plan ID | 29698MI0540803 |
| 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 | $14400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,200 |
| 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 | $14400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,200 |
| 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 MyPriority Value Bronze HSA Southeast Michigan Network Health Insurance Plan, 29698MI0540803
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about MyPriority Value Bronze HSA Southeast Michigan Network, 29698MI0540803 Health Insurance Plan, 29698MI0540803
-
Does MyPriority Value Bronze HSA Southeast Michigan Network Health Insurance Plan, 29698MI0540803 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (29698MI0540803) Health Insurance Plan, Variant (29698MI0540803-00) offer Disease Management Programs?
Does (29698MI0540803) Health Insurance Plan, Variant (29698MI0540803-00) have Out Of Country Coverage?
Does (29698MI0540803) Health Insurance Plan, Variant (29698MI0540803-00) have Out of Service Area Coverage?
Does (29698MI0540803) Health Insurance Plan, Variant (29698MI0540803-00) offer Disease Management Programs?
Does MyPriority Value Bronze HSA Southeast Michigan Network Health Insurance Plan, Variant (29698MI0540803-00) offer Disease Management Programs for Asthma?
Does MyPriority Value Bronze HSA Southeast Michigan Network Health Insurance Plan, Variant (29698MI0540803-00) offer Disease Management Programs for Heart disease?
Does MyPriority Value Bronze HSA Southeast Michigan Network Health Insurance Plan, Variant (29698MI0540803-00) offer Disease Management Programs for Depression?
Does MyPriority Value Bronze HSA Southeast Michigan Network Health Insurance Plan, Variant (29698MI0540803-00) offer Disease Management Programs for Diabetes?
Does MyPriority Value Bronze HSA Southeast Michigan Network Health Insurance Plan, Variant (29698MI0540803-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does MyPriority Value Bronze HSA Southeast Michigan Network Health Insurance Plan, Variant (29698MI0540803-00) offer Disease Management Programs for Low back pain?
Does MyPriority Value Bronze HSA Southeast Michigan Network Health Insurance Plan, Variant (29698MI0540803-00) offer Disease Management Programs for Pregnancy?
Does MyPriority Value Bronze HSA Southeast Michigan Network Health Insurance Plan, Variant (29698MI0540803-00) 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