Silver 12 with First 4 Primary Care Visits Free - 79975MS0010011 Health Insurance Plan
Molina Healthcare of Mississippi, Inc health insurance plan with the Plan ID 79975MS0010011. 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 94.16% (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 5.84% 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 | 79975MS0010011 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Mississippi | ||||||||||||||||||
| Health Insurance Issuer | Molina Healthcare of Mississippi, Inc | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 79975MS0010011-06 | ||||||||||||||||||
| Provider Network(s) | ['MSN001'] | ||||||||||||||||||
| 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 - 79975MS0010011-00 Standard On Exchange Plan - 79975MS0010011-01 Open to Indians below 300% FPL - 79975MS0010011-02 Open to Indians above 300% FPL - 79975MS0010011-03 73% AV Silver Plan - 79975MS0010011-04 |
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| Last Plan Update Date | Fri, 08 Dec 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, 79975MS0010011-06
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $2.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Must be medically necessary. Company may require a treatment plan, outlining the goals of therapy, mode of therapy, and duration of therapy, to be submitted by the provider prior to the initiation of treatment. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Limited to 20 visits for any combination of chiropractic treatment, physical therapy and occupational therapy. |
YES | $2.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Separate cost-sharing may apply for professional services. Maximum three days of facility copayments per inpatient admission. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | $4.00 |
100.00% |
| Durable Medical Equipment
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 10.00% Coinsurance after deductible |
10.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 10.00% Coinsurance after deductible |
10.00% 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
Limit: 30.0 Days per Month Coverage is limited to a 30-day supply retail or 90-day supply mail order. |
YES | $2.00 |
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 | 10.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | No Charge |
100.00% |
| Hospice Services
|
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 10.00% 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 | 10.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $2.00 |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Days per Month Coverage is limited to a 30-day supply retail or 90-day supply mail order. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | $2.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $2.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 76.0 Visit(s) per Year Limited to 36 cardiac rehabilitation visits per year, 20 speech therapy visits per year, and 20 visits for any combination of chiropractic treatment, physical therapy and occupational therapy. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Days per Month Coverage is limited to a 30-day supply retail or 90-day supply mail order. |
YES | $20.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Covered services must be included in Grade A and B Recommendations of the USPSTF and include all other preventive health services required by PPACA. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $2.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Radiation
Must be medically necessary. Company may require a treatment plan, outlining the goals of therapy, mode of therapy, and duration of therapy, to be submitted by the provider prior to the initiation of treatment. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Plan only outlines benefits for breast reconstruction. Must be medically necessary and related to mastectomy. 2 copay max |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Limited to 20 visits for any combination of chiropractic treatment, physical therapy and occupational therapy. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year |
YES | 10.00% Coinsurance after deductible |
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 | No Charge |
100.00% |
| Routine Foot Care
Requires a Diabetes diagnosis. |
YES | $2.00 |
100.00% |
| Skilled Nursing Facility
Limit: 30.0 Days per Year |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $4.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Days per Month |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $2.00 |
100.00% |
| Transplant
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $3.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 10.00% Coinsurance after deductible |
100.00% |
Silver 12 100 with First 4 Primary Care Visits Free Health Insurance Plan Variant 79975MS0010011-06 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.94161213073219 |
| 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 | 94% AV Level Silver 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 | MSF007 |
| Formulary URL | URL |
| HIOS Product ID | 79975MS001 |
| Import Date | 2023-12-08 01:02:13 |
| 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 | 79975 |
| 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 | MSN001 |
| 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) | 79975MS0010011-06 |
| Plan Marketing Name | Silver 12 with First 4 Primary Care Visits Free |
| Plan Type | HMO |
| Plan Variant Marketing Name | Silver 12 100 with First 4 Primary Care Visits Free |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,200 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $100 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $80 |
| SBC Scenario, Having Diabetes, Copayment | $300 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $10 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MSS001 |
| Source Name | HIOS |
| Plan ID | 79975MS0010011 |
| State Code | MS |
| 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 | $200 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $100 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $100 |
| 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 | $6300 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $3150 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,150 |
| 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, 79975MS0010011
| 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, 79975MS0010011 Health Insurance Plan, 79975MS0010011
-
Does Silver 12 with First 4 Primary Care Visits Free Health Insurance Plan, 79975MS0010011 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (79975MS0010011) Health Insurance Plan, Variant (79975MS0010011-06) offer Disease Management Programs?
Does (79975MS0010011) Health Insurance Plan, Variant (79975MS0010011-06) have Out Of Country Coverage?
Does (79975MS0010011) Health Insurance Plan, Variant (79975MS0010011-06) have Out of Service Area Coverage?
Does (79975MS0010011) Health Insurance Plan, Variant (79975MS0010011-06) offer Disease Management Programs?
Does Silver 12 100 with First 4 Primary Care Visits Free Health Insurance Plan, Variant (79975MS0010011-06) offer Disease Management Programs for Asthma?
Does Silver 12 100 with First 4 Primary Care Visits Free Health Insurance Plan, Variant (79975MS0010011-06) offer Disease Management Programs for Heart disease?
Does Silver 12 100 with First 4 Primary Care Visits Free Health Insurance Plan, Variant (79975MS0010011-06) offer Disease Management Programs for Depression?
Does Silver 12 100 with First 4 Primary Care Visits Free Health Insurance Plan, Variant (79975MS0010011-06) offer Disease Management Programs for Diabetes?
Does Silver 12 100 with First 4 Primary Care Visits Free Health Insurance Plan, Variant (79975MS0010011-06) offer Disease Management Programs for Pregnancy?
Does Silver 12 100 with First 4 Primary Care Visits Free Health Insurance Plan, Variant (79975MS0010011-06) 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