Select by Medica Gold Standard - 39520KS0040055 Health Insurance Plan

Medica Insurance Company health insurance plan with the Plan ID 39520KS0040055. The plan is called Select by Medica Gold Standard.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.02% (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 21.98% 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 39520KS0040055
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 39520KS0040055-01
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).

Providers Kansas All US States
All 8512 13801
PCP 1643 2791
Allergy 3 5
OB/GYN 29 42
Dentists 6 8
Available Variants of the Health Plan

Standard Off Exchange Plan - 39520KS0040055-00

Standard On Exchange Plan - 39520KS0040055-01

Open to Indians below 300% FPL - 39520KS0040055-02

Open to Indians above 300% FPL - 39520KS0040055-03

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 Gold Standard Health Insurance Plan, 39520KS0040055-01

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

25.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

25.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

25.00% Coinsurance after deductible

100.00%
Chiropractic Care
YES

$30.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

25.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

25.00% Coinsurance after deductible

100.00%
Dialysis
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Eye Glasses for Children
YES

25.00% Coinsurance after deductible

100.00%
Gender Affirming Care
YES

25.00% Coinsurance after deductible

100.00%
Generic Drugs
YES

$15.00

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

25.00% Coinsurance after deductible

100.00%
Hearing Aids
NO
Home Health Care Services
YES

25.00% Coinsurance after deductible

100.00%
Hospice Services
YES

25.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

25.00% Coinsurance after deductible

100.00%
Infertility Treatment
YES

25.00% Coinsurance after deductible

100.00%
Infusion Therapy
YES

25.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

25.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

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

25.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$30.00

100.00%
Non-Preferred Brand Drugs
YES

$60.00

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

$30.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Prescription insulin will not exceed $25 per prescription unit

YES

$30.00

100.00%
Prenatal and Postnatal Care
YES

25.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$30.00

100.00%
Private-Duty Nursing
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Radiation
YES

25.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

25.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

$30.00

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

$30.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children
YES

$30.00

100.00%
Routine Foot Care
YES

25.00% Coinsurance after deductible

100.00%
Skilled Nursing Facility
YES

25.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$60.00

100.00%
Specialty Drugs
YES

$250.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

25.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$30.00

100.00%
Transplant
YES

25.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

25.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$45.00

$45.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

25.00% Coinsurance after deductible

100.00%

Select by Medica Gold Standard Health Insurance Plan Variant 39520KS0040055-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7801851164396751
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 Gold On Exchange Plan
Dental Only Plan No
Design Type Design 1
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 KSF028
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 Gold
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) 39520KS0040055-01
Plan Marketing Name Select by Medica Gold Standard
Plan Type EPO
Plan Variant Marketing Name Select by Medica Gold Standard
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,400
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $1,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $700
SBC Scenario, Having Diabetes, Deductible $1,100
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $300
SBC Scenario, Treatment of a Simple Fracture, Copayment $100
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID KSS004
Source Name SERFF
Plan ID 39520KS0040055
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 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $3000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,500
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 $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
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 Gold Standard Health Insurance Plan, 39520KS0040055

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Select by Medica Gold Standard, 39520KS0040055 Health Insurance Plan, 39520KS0040055

  • Does Select by Medica Gold Standard Health Insurance Plan, 39520KS0040055 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (39520KS0040055) Health Insurance Plan, Variant (39520KS0040055-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does (39520KS0040055) Health Insurance Plan, Variant (39520KS0040055-01) have Out Of Country Coverage?

    Yes. Details: Emergency Services

    Does (39520KS0040055) Health Insurance Plan, Variant (39520KS0040055-01) have Out of Service Area Coverage?

    Yes. Details: Emergency Services

    Does (39520KS0040055) Health Insurance Plan, Variant (39520KS0040055-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does Select by Medica Gold Standard Health Insurance Plan, Variant (39520KS0040055-01) offer Disease Management Programs for Asthma?

    Yes, the Select by Medica Gold Standard Health Insurance Plan Variant 39520KS0040055-01 offers Disease Management Program for Asthma.

    Does Select by Medica Gold Standard Health Insurance Plan, Variant (39520KS0040055-01) offer Disease Management Programs for Heart disease?

    Yes, the Select by Medica Gold Standard Health Insurance Plan Variant 39520KS0040055-01 offers Disease Management Program for Heart disease.

    Does Select by Medica Gold Standard Health Insurance Plan, Variant (39520KS0040055-01) offer Disease Management Programs for Depression?

    Yes, the Select by Medica Gold Standard Health Insurance Plan Variant 39520KS0040055-01 offers Disease Management Program for Depression.

    Does Select by Medica Gold Standard Health Insurance Plan, Variant (39520KS0040055-01) offer Disease Management Programs for Diabetes?

    Yes, the Select by Medica Gold Standard Health Insurance Plan Variant 39520KS0040055-01 offers Disease Management Program for Diabetes.

    Does Select by Medica Gold Standard Health Insurance Plan, Variant (39520KS0040055-01) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Select by Medica Gold Standard Health Insurance Plan Variant 39520KS0040055-01 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Select by Medica Gold Standard Health Insurance Plan, Variant (39520KS0040055-01) offer Disease Management Programs for Low back pain?

    Yes, the Select by Medica Gold Standard Health Insurance Plan Variant 39520KS0040055-01 offers Disease Management Program for Low back pain.

    Does Select by Medica Gold Standard Health Insurance Plan, Variant (39520KS0040055-01) offer Disease Management Programs for Pregnancy?

    Yes, the Select by Medica Gold Standard Health Insurance Plan Variant 39520KS0040055-01 offers Disease Management Program 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