Select by Medica Bronze Premier - 39520KS0040051 Health Insurance Plan
Medica Insurance Company health insurance plan with the Plan ID 39520KS0040051. The plan is called Select by Medica Bronze Premier.
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 | 39520KS0040051 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Kansas | ||||||||||||||||||
| Health Insurance Issuer | Medica Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 39520KS0040051-02 | ||||||||||||||||||
| Provider Network(s) | STANDARDTIER PREFERRED PREFERREDTIER | ||||||||||||||||||
| 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 - 39520KS0040051-00 Standard On Exchange Plan - 39520KS0040051-01 |
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| Last Plan Update Date | Fri, 17 Nov 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Select by Medica Bronze Premier Health Insurance Plan, 39520KS0040051-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 0.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 0.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 0.00% |
100.00% |
| Chiropractic Care
|
YES | $0.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 0.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 0.00% |
100.00% |
| Dialysis
|
YES | 0.00% |
100.00% |
| Durable Medical Equipment
Benefits are limited to the amount normally available for a basic (standard) item which allows necessary function. Basic (standard) medical equipment is equipment that provides the essential function required for the treatment or amelioration of the medical condition at a Medically Necessary level. Charges for deluxe or electrically operated medical equipment are not covered, beyond the extent allowed for basic (standard) items. Deluxe describes medical equipment that has enhancements that allow for additional convenience or use beyond that provided by basic (standard) equipment. |
YES | 0.00% |
100.00% |
| Emergency Room Services
|
YES | 0.00% |
0.00% |
| Emergency Transportation/Ambulance
|
YES | 0.00% |
0.00% |
| Eye Glasses for Children
|
YES | 0.00% |
100.00% |
| Gender Affirming Care
|
YES | 0.00% |
100.00% |
| Generic Drugs
Tier 1 preferred generic drugs on Medica's Drug List are $25 and tier 2 generic drugs are $30. Go to Plan Documents to see the List of Covered Drugs. |
YES | $0.00 |
100.00% |
| Habilitation Services
Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | 0.00% |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | 0.00% |
100.00% |
| Hospice Services
|
YES | 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 0.00% |
100.00% |
| Infertility Treatment
|
YES | 0.00% |
100.00% |
| Infusion Therapy
|
YES | 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 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% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $0.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 0.00% |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Professional Providers include Physician Assistants. Registered Nurses qualify as Eligible Providers. |
YES | $0.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 0.00% |
100.00% |
| Outpatient Rehabilitation Services
Speech Therapy limited to one service per day up to a maximum benefit of 90 daily services per Insured per Benefit Period, see Rehabilitative Speech Therapy below. Please note: This visit limit does not apply to services for the treatment of autism spectrum disorder. |
YES | 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 0.00% |
100.00% |
| Preferred Brand Drugs
Prescription insulin will not exceed $25 per prescription unit |
YES | $0.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $0.00 |
100.00% |
| Private-Duty Nursing
|
YES | 0.00% |
100.00% |
| Prosthetic Devices
Benefits are limited to the amount normally available for a basic (standard) appliance which allows necessary function. Basic (standard) medical devices or appliances are those that provide the essential function required for the treatment or amelioration of the medical condition at a Medically Necessary level. |
YES | 0.00% |
100.00% |
| Radiation
|
YES | 0.00% |
100.00% |
| Reconstructive Surgery
|
YES | 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | 0.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 90.0 Days per Benefit Period Limited to one service per day up to a maximum benefit of 90 daily services per Insured per Benefit Period. Please note: This visit limit does not apply to services for the treatment of autism spectrum disorder. |
YES | 0.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
|
YES | $0.00 |
100.00% |
| Routine Foot Care
|
YES | 0.00% |
100.00% |
| Skilled Nursing Facility
|
YES | 0.00% |
100.00% |
| Specialist Visit
|
YES | $0.00 |
100.00% |
| Specialty Drugs
|
YES | $0.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $0.00 |
100.00% |
| Transplant
|
YES | 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 0.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $0.00 |
$0.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 0.00% |
100.00% |
Select by Medica Bronze Premier Health Insurance Plan Variant 39520KS0040051-02 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 | 2024 |
| 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 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | KSF026 |
| Formulary URL | URL |
| HIOS Product ID | 39520KS004 |
| Import Date | 2023-11-17 20:01:49 |
| 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 | 39520 |
| Issuer Marketplace Marketing Name | Medica |
| 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 | KSN004 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 39520KS0040051-02 |
| Plan Marketing Name | Select by Medica Bronze Premier |
| Plan Type | EPO |
| Plan Variant Marketing Name | Select by Medica Bronze Premier |
| 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 | $0 |
| 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 | KSS004 |
| Source Name | SERFF |
| Plan ID | 39520KS0040051 |
| State Code | KS |
| 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 Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Select by Medica Bronze Premier Health Insurance Plan, 39520KS0040051
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Select by Medica Bronze Premier, 39520KS0040051 Health Insurance Plan, 39520KS0040051
-
Does Select by Medica Bronze Premier Health Insurance Plan, 39520KS0040051 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (39520KS0040051) Health Insurance Plan, Variant (39520KS0040051-02) offer Disease Management Programs?
Does (39520KS0040051) Health Insurance Plan, Variant (39520KS0040051-02) have Out Of Country Coverage?
Does (39520KS0040051) Health Insurance Plan, Variant (39520KS0040051-02) have Out of Service Area Coverage?
Does (39520KS0040051) Health Insurance Plan, Variant (39520KS0040051-02) offer Disease Management Programs?
Does Select by Medica Bronze Premier Health Insurance Plan, Variant (39520KS0040051-02) offer Disease Management Programs for Asthma?
Does Select by Medica Bronze Premier Health Insurance Plan, Variant (39520KS0040051-02) offer Disease Management Programs for Heart disease?
Does Select by Medica Bronze Premier Health Insurance Plan, Variant (39520KS0040051-02) offer Disease Management Programs for Depression?
Does Select by Medica Bronze Premier Health Insurance Plan, Variant (39520KS0040051-02) offer Disease Management Programs for Diabetes?
Does Select by Medica Bronze Premier Health Insurance Plan, Variant (39520KS0040051-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Select by Medica Bronze Premier Health Insurance Plan, Variant (39520KS0040051-02) offer Disease Management Programs for Low back pain?
Does Select by Medica Bronze Premier Health Insurance Plan, Variant (39520KS0040051-02) offer Disease Management Programs for Pregnancy?
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