Silver 1 with Adult Vision Services - 42326SC0020002 Health Insurance Plan
MOLINA HEALTHCARE OF SOUTH CAROLINA, INC health insurance plan with the Plan ID 42326SC0020002. The plan is called Silver 1 with Adult Vision Services.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.00% (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 30.00% 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 | 42326SC0020002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | South Carolina | ||||||||||||||||||
| Health Insurance Issuer | MOLINA HEALTHCARE OF SOUTH CAROLINA, INC | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 42326SC0020002-03 | ||||||||||||||||||
| Provider Network(s) | ['SCN001'] | ||||||||||||||||||
| 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 - 42326SC0020002-00 Standard On Exchange Plan - 42326SC0020002-01 Open to Indians below 300% FPL - 42326SC0020002-02 Open to Indians above 300% FPL - 42326SC0020002-03 73% AV Silver Plan - 42326SC0020002-04 |
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| Last Plan Update Date | Thu, 10 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Silver 1 with Adult Vision Services Health Insurance Plan, 42326SC0020002-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $35.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Spinal manipulation covered as part of medically necessary Rehabilitation Services only that can be provided by a chiropractor within the scope of a chiropractic license; however, general chiropractic benefits are not covered. |
YES | $35.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Separate cost-sharing may apply for professional services. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Diabetes self-management training and education will be provided on an outpatient basis when done by a registered or licensed health care professional that is certified in diabetes. |
YES | No Charge |
100.00% |
| Dialysis
|
YES | $60.00 |
100.00% |
| Durable Medical Equipment
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
|
YES | $20.00 |
100.00% |
| Habilitation Services
|
YES | $35.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 60.0 Visit(s) per Benefit Period |
YES | No Charge |
100.00% |
| Hospice Services
|
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $75.00 |
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 | 40.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage, Schedule of Benefits, and the Evidence of Coverage for more information on other MH/SUD outpatient services, which may apply a different cost share amount and require Prior Authorization. |
YES | $35.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $35.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
|
YES | $35.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $75.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Mammography services, OBGYN exams, pap smear services, prostate services, and routine colorectal cancer screening/testing. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $35.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Reconstructive Surgery that is considered a Covered Expense is limited to Surgery: To correct a functional defect that results from a birth defect, disease and anomaly; or Performed to correct a seriously disfiguring condition resulting from injury; or For breast reconstruction after a mastectomy. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period Physical Therapy, Occupational Therapy and Speech Therapy are limited to a 30-visit limit per therapy per year. |
YES | $35.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period Physical Therapy, Occupational Therapy and Speech Therapy are limited to a 30-visit limit per therapy per year. |
YES | $35.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Benefit Period |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage, Schedule of Benefits, and the Evidence of Coverage for more information on other MH/SUD outpatient services, which may apply a different cost share amount and require Prior Authorization. |
YES | $35.00 |
100.00% |
| Transplant
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $55.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $95.00 |
100.00% |
Silver 1 LCS with Adult Vision Services Health Insurance Plan Variant 42326SC0020002-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.700016463126938 |
| 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 | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.9904672158815541 |
| First Tier Utilization | 100% |
| Formulary ID | SCF002 |
| Formulary URL | URL |
| HIOS Product ID | 42326SC002 |
| Import Date | 2024-10-10 01:01:49 |
| 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 | 42326 |
| Issuer Marketplace Marketing Name | Molina Healthcare |
| 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 | SCN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 42326SC0020002-03 |
| Plan Marketing Name | Silver 1 with Adult Vision Services |
| Plan Type | HMO |
| Plan Variant Marketing Name | Silver 1 LCS with Adult Vision Services |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,400 |
| SBC Scenario, Having a Baby, Copayment | $800 |
| SBC Scenario, Having a Baby, Deductible | $5,750 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $3,900 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,600 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | SCS001 |
| Source Name | HIOS |
| Plan ID | 42326SC0020002 |
| State Code | SC |
| 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 | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $11500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5750 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,750 |
| 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 | $15880 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7940 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,940 |
| 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 | Yes |
Copay & Coinsurance of Silver 1 with Adult Vision Services Health Insurance Plan, 42326SC0020002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Silver 1 with Adult Vision Services, 42326SC0020002 Health Insurance Plan, 42326SC0020002
-
Does Silver 1 with Adult Vision Services Health Insurance Plan, 42326SC0020002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (42326SC0020002) Health Insurance Plan, Variant (42326SC0020002-03) offer Disease Management Programs?
Does (42326SC0020002) Health Insurance Plan, Variant (42326SC0020002-03) have Out Of Country Coverage?
Does (42326SC0020002) Health Insurance Plan, Variant (42326SC0020002-03) have Out of Service Area Coverage?
Does (42326SC0020002) Health Insurance Plan, Variant (42326SC0020002-03) offer Disease Management Programs?
Does Silver 1 LCS with Adult Vision Services Health Insurance Plan, Variant (42326SC0020002-03) offer Disease Management Programs for Asthma?
Does Silver 1 LCS with Adult Vision Services Health Insurance Plan, Variant (42326SC0020002-03) offer Disease Management Programs for Heart disease?
Does Silver 1 LCS with Adult Vision Services Health Insurance Plan, Variant (42326SC0020002-03) offer Disease Management Programs for Depression?
Does Silver 1 LCS with Adult Vision Services Health Insurance Plan, Variant (42326SC0020002-03) offer Disease Management Programs for Diabetes?
Does Silver 1 LCS with Adult Vision Services Health Insurance Plan, Variant (42326SC0020002-03) offer Disease Management Programs for Pregnancy?
Does Silver 1 LCS with Adult Vision Services Health Insurance Plan, Variant (42326SC0020002-03) offer Disease Management Programs for Weight loss programs?
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