Premier Silver + Vision + Adult Dental - 99723MO0110014 Health Insurance Plan
Celtic Insurance Company health insurance plan with the Plan ID 99723MO0110014. The plan is called Premier Silver + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 73.49% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 26.51% 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 74.46% (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 25.54% 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 | 99723MO0110014 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Missouri | ||||||||||||||||||
| Health Insurance Issuer | Celtic Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 99723MO0110014-04 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| 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 - 99723MO0110014-00 Standard On Exchange Plan - 99723MO0110014-01 Open to Indians below 300% FPL - 99723MO0110014-02 Open to Indians above 300% FPL - 99723MO0110014-03 73% AV Silver Plan - 99723MO0110014-04 |
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| Last Plan Update Date | Wed, 14 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Premier Silver + Vision + Adult Dental Health Insurance Plan, 99723MO0110014-04
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $45.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
100.00% |
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
Limit: 26.0 Visit(s) per Year Chiropractic visits beyond 26 per benefit period require Prior Authorization. |
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 | $45.00 |
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
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Covered lenses and frames each available at limit of one per year. |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | No Charge after deductible |
100.00% |
| Generic Drugs
Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information. |
YES | $3.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year Limited to 20 visits per year per therapy (occupational therapy, physical therapy). No Limit for speech therapy. Limited to 36 visits per year cardiac therapy. No Limit for pulmonary therapy. |
YES | $15.00 |
100.00% |
| Hearing Aids
Limit: 2.0 Item(s) per Year Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit. |
YES | No Charge after deductible |
100.00% |
| Home Health Care Services
Limit: 100.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Hospice Services
Respite Care is covered as part of hospice services only. |
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). |
NO | ||
| 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
Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit. |
NO | ||
| Major Dental Care - Adult
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
100.00% |
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Emergency Room
|
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health ER Physician Fee
|
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
Note: Services (excluding emergency services) rendered by an out-of-network?provider are not covered under this plan, with the exception of two (2) sessions per year for diagnosis/assessment by a licensed mental health provider. |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. Services (excluding emergency services) rendered by an out-of-network?provider are not covered under this plan, with the exception of two (2) sessions per year for diagnosis/assessment by a licensed mental health provider. |
YES | $15.00 |
100.00% |
| Mental/Behavioral Health Urgent Care
|
YES | $15.00 |
$15.00 |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
|
YES | $45.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $15.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Limited to 20 visits per year per therapy (occupational therapy, physical therapy). No Limit for speech therapy. Limited to 36 visits per year cardiac therapy. No Limit for pulmonary therapy. |
YES | $15.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $50.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $15.00 |
100.00% |
| Preventive Care/Screening/Immunization
Covered in accordance with ACA guidelines. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Unlimited Virtual 24/7 Care Visits received from Ambetter?s designated telehealth provider covered at No Charge, except for HSAs. |
YES | $15.00 |
100.00% |
| Private-Duty Nursing
Limit: 82.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Prosthetic Devices
Benefits include the purchase, fitting, adjustments, repairs and replacements. |
YES | No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Limited to 20 visits per year per therapy (occupational therapy, physical therapy). No Limit for speech therapy. Limited to 36 visits per year cardiac therapy. No Limit for pulmonary therapy. |
YES | $15.00 |
100.00% |
| Rehabilitative Speech Therapy
|
YES | $15.00 |
100.00% |
| Routine Dental Services (Adult)
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eye glasses. |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
YES | $45.00 |
100.00% |
| Skilled Nursing Facility
Limit: 150.0 Days per Year |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | $45.00 |
100.00% |
| Specialty Drugs
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. Services (excluding emergency services) rendered by an out-of-network?provider are not covered under this plan, with the exception of two (2) sessions per year for diagnosis/assessment by a licensed mental health provider. |
YES | $15.00 |
100.00% |
| Substance Use Disorder Emergency Room
|
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder ER Physician Fee
|
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder Outpatient Other Services
|
YES | No Charge after deductible |
100.00% |
| Substance Use Disorder Urgent Care
|
YES | $15.00 |
$15.00 |
| Tier 1b Generic Drugs
Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information. |
YES | $15.00 |
100.00% |
| Transplant
Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. |
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $45.00 |
$45.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Covered in accordance with ACA guidelines. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
100.00% |
Premier Silver + Vision + Adult Dental Health Insurance Plan Variant 99723MO0110014-04 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7446392127991239 |
| 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 | 73% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 0.9672 |
| First Tier Utilization | 100% |
| Formulary ID | MOF001 |
| Formulary URL | URL |
| HIOS Product ID | 99723MO011 |
| Import Date | 2024-08-14 01:01:35 |
| 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 | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 73.49% |
| Issuer ID | 99723 |
| Issuer Marketplace Marketing Name | Ambetter from Home State Health |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MON001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 99723MO0110014-04 |
| Plan Marketing Name | Premier Silver + Vision + Adult Dental |
| Plan Type | EPO |
| Plan Variant Marketing Name | Premier Silver + Vision + Adult Dental |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $20 |
| 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 | $1,000 |
| 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 | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,100 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MOS001 |
| Source Name | HIOS |
| Plan ID | 99723MO0110014 |
| State Code | MO |
| 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 | $14500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7250 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,250 |
| 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 | $14500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7250 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,250 |
| 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 Premier Silver + Vision + Adult Dental Health Insurance Plan, 99723MO0110014
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Premier Silver + Vision + Adult Dental, 99723MO0110014 Health Insurance Plan, 99723MO0110014
-
Does Premier Silver + Vision + Adult Dental Health Insurance Plan, 99723MO0110014 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (99723MO0110014) Health Insurance Plan, Variant (99723MO0110014-04) offer Disease Management Programs?
Does (99723MO0110014) Health Insurance Plan, Variant (99723MO0110014-04) have Out Of Country Coverage?
Does (99723MO0110014) Health Insurance Plan, Variant (99723MO0110014-04) have Out of Service Area Coverage?
Does (99723MO0110014) Health Insurance Plan, Variant (99723MO0110014-04) offer Disease Management Programs?
Does Premier Silver + Vision + Adult Dental Health Insurance Plan, Variant (99723MO0110014-04) offer Disease Management Programs for Asthma?
Does Premier Silver + Vision + Adult Dental Health Insurance Plan, Variant (99723MO0110014-04) offer Disease Management Programs for Heart disease?
Does Premier Silver + Vision + Adult Dental Health Insurance Plan, Variant (99723MO0110014-04) offer Disease Management Programs for Diabetes?
Does Premier Silver + Vision + Adult Dental Health Insurance Plan, Variant (99723MO0110014-04) offer Disease Management Programs for Pregnancy?
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