Silver 12 with First 4 Primary Care Visits Free - 54172FL0010011 Health Insurance Plan
Molina Healthcare of Florida, Inc health insurance plan with the Plan ID 54172FL0010011. The plan is called Silver 12 with First 4 Primary Care Visits Free.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.21% (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 29.79% 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 | 54172FL0010011 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Florida | ||||||||||||||||||
| Health Insurance Issuer | Molina Healthcare of Florida, Inc | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 54172FL0010011-00 | ||||||||||||||||||
| Provider Network(s) | ['FLN001'] | ||||||||||||||||||
| 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 - 54172FL0010011-00 Standard On Exchange Plan - 54172FL0010011-01 Open to Indians below 300% FPL - 54172FL0010011-02 Open to Indians above 300% FPL - 54172FL0010011-03 73% AV Silver Plan - 54172FL0010011-04 |
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| Last Plan Update Date | Wed, 20 Sep 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Silver 12 with First 4 Primary Care Visits Free Health Insurance Plan, 54172FL0010011-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $40.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 26.0 Visit(s) per Benefit Period Combined 35 visits/yr for all OP therapies, of which up to 26 may be for Chiropractic Care |
YES | $40.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | $75.00 |
100.00% |
| Durable Medical Equipment
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
|
YES | $10.00 |
100.00% |
| Habilitation Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Hospice Services
|
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 20.00% 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 | 20.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $40.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 20.00% 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 | $40.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Benefit Period Combined 35 visits/yr for all OP therapies, of which up to 26 may be for Chiropractic Care |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $100.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $40.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Benefit Period Combined 35 visits/yr for all OP therapies, of which up to 26 may be for Chiropractic Care |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Benefit Period Combined 35 visits/yr for all OP therapies, of which up to 26 may be for Chiropractic Care |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
YES | $40.00 |
100.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $75.00 |
100.00% |
| Specialty Drugs
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $40.00 |
100.00% |
| Transplant
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Limit: 2.0 Procedure(s) per Year two TMJ procedures per year and one splint per six-month period |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $60.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Silver 12 Off Exchange with First 4 Primary Care Visits Free Health Insurance Plan Variant 54172FL0010011-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7021390278069211 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 4 |
| 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 Silver Off Exchange Plan |
| 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 | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | FLF007 |
| Formulary URL | URL |
| HIOS Product ID | 54172FL001 |
| Import Date | 2023-09-20 01:01:24 |
| 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? | Yes |
| Issuer ID | 54172 |
| 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 | FLN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 54172FL0010011-00 |
| Plan Marketing Name | Silver 12 with First 4 Primary Care Visits Free |
| Plan Type | HMO |
| Plan Variant Marketing Name | Silver 12 Off Exchange with First 4 Primary Care Visits Free |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,100 |
| SBC Scenario, Having a Baby, Copayment | $60 |
| SBC Scenario, Having a Baby, Deductible | $7,000 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,800 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| 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 | FLS001 |
| Source Name | HIOS |
| Specialist Requiring a Referral | All Specialties except Podiatry, Chiropractic, Dermatology (first 5 visits), Obstetrician and Gynecologist (OB/GYN) |
| Plan ID | 54172FL0010011 |
| State Code | FL |
| 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 | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $14000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,000 |
| 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 | $18900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9450 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,450 |
| 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 12 with First 4 Primary Care Visits Free Health Insurance Plan, 54172FL0010011
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Silver 12 with First 4 Primary Care Visits Free, 54172FL0010011 Health Insurance Plan, 54172FL0010011
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Does Silver 12 with First 4 Primary Care Visits Free Health Insurance Plan, 54172FL0010011 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (54172FL0010011) Health Insurance Plan, Variant (54172FL0010011-00) offer Disease Management Programs?
Does (54172FL0010011) Health Insurance Plan, Variant (54172FL0010011-00) have Out Of Country Coverage?
Does (54172FL0010011) Health Insurance Plan, Variant (54172FL0010011-00) have Out of Service Area Coverage?
Does (54172FL0010011) Health Insurance Plan, Variant (54172FL0010011-00) offer Disease Management Programs?
Does Silver 12 Off Exchange with First 4 Primary Care Visits Free Health Insurance Plan, Variant (54172FL0010011-00) offer Disease Management Programs for Asthma?
Does Silver 12 Off Exchange with First 4 Primary Care Visits Free Health Insurance Plan, Variant (54172FL0010011-00) offer Disease Management Programs for Heart disease?
Does Silver 12 Off Exchange with First 4 Primary Care Visits Free Health Insurance Plan, Variant (54172FL0010011-00) offer Disease Management Programs for Depression?
Does Silver 12 Off Exchange with First 4 Primary Care Visits Free Health Insurance Plan, Variant (54172FL0010011-00) offer Disease Management Programs for Diabetes?
Does Silver 12 Off Exchange with First 4 Primary Care Visits Free Health Insurance Plan, Variant (54172FL0010011-00) offer Disease Management Programs for Pregnancy?
Does Silver 12 Off Exchange with First 4 Primary Care Visits Free Health Insurance Plan, Variant (54172FL0010011-00) 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