Select by Medica Silver Share - 53461MO0010075 Health Insurance Plan
Medica Insurance Company health insurance plan with the Plan ID 53461MO0010075. The plan is called Select by Medica Silver Share.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.02% (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 5.98% 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 | 53461MO0010075 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Missouri | ||||||||||||||||||
| Health Insurance Issuer | Medica Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 53461MO0010075-06 | ||||||||||||||||||
| 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 - 53461MO0010075-00 Standard On Exchange Plan - 53461MO0010075-01 Open to Indians below 300% FPL - 53461MO0010075-02 Open to Indians above 300% FPL - 53461MO0010075-03 73% AV Silver Plan - 53461MO0010075-04 |
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| Last Plan Update Date | Thu, 19 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Select by Medica Silver Share Health Insurance Plan, 53461MO0010075-06
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 10.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 10.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | $35.00 |
100.00% |
| Chiropractic Care
|
YES | $5.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 10.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | 10.00% |
100.00% |
| Durable Medical Equipment
|
YES | 10.00% |
100.00% |
| Emergency Room Services
|
YES | 10.00% |
10.00% |
| Emergency Transportation/Ambulance
|
YES | 10.00% |
10.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year See policy or plan document for additional benefit explanation. |
YES | 10.00% |
100.00% |
| Gender Affirming Care
|
YES | 10.00% |
100.00% |
| Generic Drugs
|
YES | $5.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Benefit Period See policy or plan document for additional benefit explanation. |
YES | 10.00% |
100.00% |
| Hearing Aids
See policy or plan document for additional benefit explanation. |
YES | 10.00% |
100.00% |
| Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period See policy or plan document for additional benefit explanation. |
YES | 10.00% |
100.00% |
| Hospice Services
|
YES | 10.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 10.00% |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 10.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 10.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 10.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 10.00% |
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 | 10.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $5.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 60.00% |
100.00% |
| Nutritional Counseling
|
YES | 10.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $5.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 10.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Benefit Period See policy or plan document for additional benefit explanation. |
YES | 10.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 10.00% |
100.00% |
| Preferred Brand Drugs
|
YES | $125.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 10.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Virtual visits are unlimited with a $0 copayment when provided by a designated in-network virtual care provider for non-urgent medical symptoms for common illnesses. |
YES | $5.00 |
100.00% |
| Private-Duty Nursing
Limit: 82.0 Visit(s) per Benefit Period |
YES | 10.00% |
100.00% |
| Prosthetic Devices
|
YES | 10.00% |
100.00% |
| Radiation
|
YES | 10.00% |
100.00% |
| Reconstructive Surgery
|
YES | 10.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Benefit Period See policy or plan document for additional benefit explanation. |
YES | 10.00% |
100.00% |
| Rehabilitative Speech Therapy
See policy or plan document for additional benefit explanation. |
YES | 10.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period |
YES | $5.00 |
100.00% |
| Routine Foot Care
See policy or plan document for additional benefit explanation. |
YES | 10.00% |
100.00% |
| Skilled Nursing Facility
Limit: 150.0 Days per Benefit Period |
YES | 10.00% |
100.00% |
| Specialist Visit
|
YES | $35.00 |
100.00% |
| Specialty Drugs
|
YES | $700.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 10.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $5.00 |
100.00% |
| Transplant
|
YES | 10.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 10.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | 10.00% |
10.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 10.00% |
100.00% |
Select by Medica Silver Share Health Insurance Plan Variant 53461MO0010075-06 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.9402335515831021 |
| 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 | 94% AV Level Silver 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 |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | MOF008 |
| Formulary URL | URL |
| HIOS Product ID | 53461MO001 |
| Import Date | 2024-09-19 01:01:32 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 53461 |
| Issuer Marketplace Marketing Name | Medica |
| 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 | Yes |
| Out of Service Area Coverage Description | Emergency Services |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 53461MO0010075-06 |
| Plan Marketing Name | Select by Medica Silver Share |
| Plan Type | EPO |
| Plan Variant Marketing Name | Select by Medica Silver Share |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,100 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $800 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $80 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MOS001 |
| Source Name | HIOS |
| Plan ID | 53461MO0010075 |
| 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 | 10.00% |
| 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 | $3050 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $1525 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $1,525 |
| 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 Silver Share Health Insurance Plan, 53461MO0010075
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Select by Medica Silver Share, 53461MO0010075 Health Insurance Plan, 53461MO0010075
-
Does Select by Medica Silver Share Health Insurance Plan, 53461MO0010075 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (53461MO0010075) Health Insurance Plan, Variant (53461MO0010075-06) offer Disease Management Programs?
Does (53461MO0010075) Health Insurance Plan, Variant (53461MO0010075-06) have Out Of Country Coverage?
Does (53461MO0010075) Health Insurance Plan, Variant (53461MO0010075-06) have Out of Service Area Coverage?
Does (53461MO0010075) Health Insurance Plan, Variant (53461MO0010075-06) offer Disease Management Programs?
Does Select by Medica Silver Share Health Insurance Plan, Variant (53461MO0010075-06) offer Disease Management Programs for Asthma?
Does Select by Medica Silver Share Health Insurance Plan, Variant (53461MO0010075-06) offer Disease Management Programs for Heart disease?
Does Select by Medica Silver Share Health Insurance Plan, Variant (53461MO0010075-06) offer Disease Management Programs for Depression?
Does Select by Medica Silver Share Health Insurance Plan, Variant (53461MO0010075-06) offer Disease Management Programs for Diabetes?
Does Select by Medica Silver Share Health Insurance Plan, Variant (53461MO0010075-06) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Select by Medica Silver Share Health Insurance Plan, Variant (53461MO0010075-06) offer Disease Management Programs for Low back pain?
Does Select by Medica Silver Share Health Insurance Plan, Variant (53461MO0010075-06) 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