SilverSelect w/ Virtual & Wellness ON-EX - 99969OH0080495 Health Insurance Plan
Medical Health Insuring Corp. of Ohio health insurance plan with the Plan ID 99969OH0080495. The plan is called SilverSelect w/ Virtual & Wellness ON-EX.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.11% (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 29.89% 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 | 99969OH0080495 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Ohio | ||||||||||||||||||
| Health Insurance Issuer | Medical Health Insuring Corp. of Ohio | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Health Insurance Plan Variant | 99969OH0080495-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| 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 - 99969OH0080495-00 Standard On Exchange Plan - 99969OH0080495-01 Open to Indians below 300% FPL - 99969OH0080495-02 Open to Indians above 300% FPL - 99969OH0080495-03 73% AV Silver Plan - 99969OH0080495-04 |
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| Last Plan Update Date | Thu, 17 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of SilverSelect w/ Virtual & Wellness ON-EX Health Insurance Plan, 99969OH0080495-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $200.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $30.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | No Charge |
100.00% |
| Chemotherapy
|
YES | $60.00 |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Benefit Period |
YES | $60.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
2 day maximum copay charge |
YES | $2,500.00 |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Exam(s) per Benefit Period |
YES | No Charge |
100.00% |
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | 50.00% |
100.00% |
| Durable Medical Equipment
Cochlear implants are covered. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period. |
YES | 50.00% |
100.00% |
| Emergency Room Services
|
YES | $1,500.00 |
$1,500.00 |
| Emergency Transportation/Ambulance
|
YES | $1,000.00 |
$1,000.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 50.00% |
100.00% |
| Gender Affirming Care
|
YES | 50.00% |
100.00% |
| Generic Drugs
Tier 1 Generics include only the drugs listed in Tier 1A Generic Standard Plus Preventive on the ACA Advantage Formulary. Tier 2 Generics are all other generic medications listed on the ACA Advantage Formulary under Tier 1B. Generic drugs are copies of brand-name drugs that contain the same active ingredients but are usually less expensive. They also must meet the same strict U.S. Food and Drug Administration (FDA) standards for quality, strength and purity. If you fill a Generic drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual. |
YES | Tier 1: $0.00 Tier 2: $20.00 |
100.00% |
| Habilitation Services
|
YES | $60.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period |
YES | $60.00 |
100.00% |
| Hospice Services
|
YES | 50.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $250.00 |
100.00% |
| Infertility Treatment
Only diagnostic and exploratory procedures required to diagnose infertility and certain surgical procedures to correct the medically diagnosed disease or condition of the reproductive organs are covered. |
YES | 50.00% |
100.00% |
| Infusion Therapy
|
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services. Maximum of 2 days for charging an inpatient copay. |
YES | $2500.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
One (1) Inpatient visit per day per Physican or other Professional Provider |
YES | $200.00 |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $120.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | No Charge |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | $2500.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for?detailed information. |
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
Non-preferred Brand-name drugs, your third cost-share tier, are included in Medical Mutual?s formulary but are typically more expensive than similar Preferred Brand-name drugs. If you fill a Non-preferred Brand-name drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | 50.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Medically necessary only |
YES | No Charge |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $1,000.00 |
100.00% |
| Outpatient Rehabilitation Services
20 visits for Speech Therapy, 20 visits for Pulmonary Rehabilitation and 36 visits for Cardiac Rehabilitation.? Benefit also includes Physical Medicine and Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services. |
YES | $60.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $200.00 |
100.00% |
| Preferred Brand Drugs
Preferred Brand-name drugs, your second cost-share tier, are included in Medical Mutual's formulary and are typically less expensive than similar Non-preferred Brand-name drugs. They are safe, effective alternatives to other brand-name drugs that may cost more. If you fill a Preferred Brand-name drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Prenatal and Postnatal Care
2 day maximum copay charge |
YES | $2,500.00 |
100.00% |
| Preventive Care/Screening/Immunization
Pap test - one per benefit period. Mammogram - one per benefit period. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
On Demand Telemedicine: 0% after $0 Copay |
YES | $30.00 |
100.00% |
| Private-Duty Nursing
Limit: 90.0 Days per Benefit Period |
YES | $60.00 |
100.00% |
| Prosthetic Devices
|
YES | 50.00% |
100.00% |
| Radiation
|
YES | 50.00% |
100.00% |
| Reconstructive Surgery
|
YES | $1,000.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Benefit Period 20 visits for Rehabilitative Occupational Therapy and 20 visits for Rehabilitative Physical Therapy |
YES | $60.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period |
YES | $60.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Preventive services only.? See plan certificate for more information. |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 90.0 Days per Benefit Period 2 day maximum copay charge |
YES | $2500.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
Specialty drugs must be obtained through a contracted specialty pharmacy, and are limited to a 30-day supply. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $2500.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for?detailed information. |
YES | $30.00 |
100.00% |
| Transplant
Per Transplant: $30,000 maximum for unrelated donor search. $10,000 maximum for transportation, meals & lodging. |
YES | $2,500.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $50.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $120.00 |
100.00% |
SilverSelect w/ Virtual & Wellness ON-EX Health Insurance Plan Variant 99969OH0080495-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7011445560513281 |
| 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 | Standard Silver Off Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $10000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5000 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $5,000 |
| Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 2), Family Per Group | $10000 per group |
| Drug EHB Deductible, In Network (Tier 2), Family Per Person | $5000 per person |
| Drug EHB Deductible, In Network (Tier 2), Individual | $5,000 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Diabetes |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 20% |
| Formulary ID | OHF003 |
| Formulary URL | URL |
| HIOS Product ID | 99969OH008 |
| Import Date | 2024-10-17 20:01:47 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 2 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 99969 |
| Issuer Marketplace Marketing Name | MedMutual |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 50.00% |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 2), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Silver |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | OHN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Covered as Non-Network |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 99969OH0080495-00 |
| Plan Marketing Name | SilverSelect w/ Virtual & Wellness ON-EX |
| Plan Type | HMO |
| Plan Variant Marketing Name | SilverSelect w/ Virtual & Wellness ON-EX |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $2,900 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,200 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,000 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 80% |
| Service Area ID | OHS001 |
| Source Name | SERFF |
| Plan ID | 99969OH0080495 |
| State Code | OH |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $17000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $8500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $8,500 |
| 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 SilverSelect w/ Virtual & Wellness ON-EX Health Insurance Plan, 99969OH0080495
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about SilverSelect w/ Virtual & Wellness ON-EX, 99969OH0080495 Health Insurance Plan, 99969OH0080495
-
Does SilverSelect w/ Virtual & Wellness ON-EX Health Insurance Plan, 99969OH0080495 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (99969OH0080495) Health Insurance Plan, Variant (99969OH0080495-00) offer Disease Management Programs?
Does (99969OH0080495) Health Insurance Plan, Variant (99969OH0080495-00) have Out Of Country Coverage?
Does (99969OH0080495) Health Insurance Plan, Variant (99969OH0080495-00) have Out of Service Area Coverage?
Does (99969OH0080495) Health Insurance Plan, Variant (99969OH0080495-00) offer Disease Management Programs?
Does SilverSelect w/ Virtual & Wellness ON-EX Health Insurance Plan, Variant (99969OH0080495-00) offer Disease Management Programs for Asthma?
Does SilverSelect w/ Virtual & Wellness ON-EX Health Insurance Plan, Variant (99969OH0080495-00) offer Disease Management Programs for Diabetes?
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