UHC Silver Value+ (Dental + Vision, No Referrals) - 71667MI0050004 Health Insurance Plan
UnitedHealthcare Community Plan, Inc. health insurance plan with the Plan ID 71667MI0050004. The plan is called UHC Silver Value+ (Dental + Vision, No Referrals).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 94.17% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 5.83% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 71667MI0050004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | UnitedHealthcare Community Plan, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 71667MI0050004-06 | ||||||||||||||||||
| Provider Network(s) | NETWORK NON-PREFERRED | ||||||||||||||||||
| 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 - 71667MI0050004-00 Standard On Exchange Plan - 71667MI0050004-01 Open to Indians below 300% FPL - 71667MI0050004-02 Open to Indians above 300% FPL - 71667MI0050004-03 73% AV Silver Plan - 71667MI0050004-04 |
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| Last Plan Update Date | Thu, 15 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of UHC Silver Value+ (Dental + Vision, No Referrals) Health Insurance Plan, 71667MI0050004-06
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 15.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $15.00 |
100.00% |
| Bariatric Surgery
|
YES | 15.00% |
100.00% |
| Basic Dental Care - Adult
Limit: 1000.0 Dollars per Year 1,000 annual benefit maximum includes all Dental Services (Routine, Basic and Major) for Adults; Excluded from In-Network Deductible and Out-of-Pocket Limit |
YES | 50.00% |
100.00% |
| Basic Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 15.00% |
100.00% |
| Chemotherapy
|
YES | 15.00% |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Limit combined with Occupational and Physical Therapy. |
YES | 15.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services follow inpatient physician/surgeon fees. |
YES | 15.00% |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | No Charge |
100.00% |
| Diabetes Education
|
YES | 15.00% |
100.00% |
| Dialysis
|
YES | 15.00% |
100.00% |
| Durable Medical Equipment
|
YES | 15.00% |
100.00% |
| Emergency Room Services
|
YES | 40.00% |
40.00% |
| Emergency Transportation/Ambulance
|
YES | 40.00% |
40.00% |
| Eye Glasses - Adult
Limit: 1.0 Item(s) per Year Excluded from In-Network Out-of-Pocket Limit |
YES | $25.00 |
100.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 15.00% |
100.00% |
| Gender Affirming Care
Covered when medically necessary. |
YES | 15.00% |
100.00% |
| Generic Drugs
Limit: 30.0 Days per Month Members can obtain a 1 month supply through network pharmacies or home delivery. Members also have the option to receive a 3 month supply through network pharmacy or home delivery. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | $3.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Limited to 30 visits per year combined for Physical Therapy, Occupational Therapy and Manipulative Treatment; 30 visits per year for Speech Therapy. Visit limits for physical, occupational and speech therapies do not apply for Autism Spectrum Disorder. |
YES | 15.00% |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | 15.00% |
100.00% |
| Hospice Services
Coverage includes inpatient and outpatient hospice care. |
YES | 15.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 15.00% |
100.00% |
| Infertility Treatment
Exclusions: Health care services and related expenses for infertility treatments, including assisted reproductive technology, in vitro fertilization, in vivo fertilization, or any other medically-aided insemination procedure, regardless of the reason for the treatment, except when performed for the diagnosis, treatment and correction of the underlying causes of infertility. Plan covers Diagnosis and treatment of cause of infertility. Benefits are available for covered services such as office visits, laboratory tests, and radiological studies to diagnose the cause of infertility. Benefits are also provided for the necessary treatment of the condition unless the treatment is identified as non-covered (see exclusions). Depending upon where the covered service is provided, benefits will be the same as those stated under each health care service category. |
YES | 15.00% |
100.00% |
| Infusion Therapy
|
YES | 15.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 15.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 15.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $3.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
Limit: 1000.0 Dollars per Year 1,000 annual benefit maximum includes all Dental Services (Routine, Basic and Major) for Adults; Excluded from In-Network Deductible and Out-of-Pocket Limit |
YES | 50.00% |
100.00% |
| Major Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 15.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 15.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost share applies to office visits, please see SBC for Mental Health Outpatient Services. |
YES | No Charge |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Days per Month Members can obtain a 1 month supply through network pharmacies or home delivery. Members also have the option to receive a 3 month supply through network pharmacy or home delivery. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | 40.00% |
100.00% |
| Nutritional Counseling
Limit: 6.0 Visit(s) per Year Consultations for dietitian services with a licensed dietitian are limited to 6 visits per year. |
YES | 15.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 15.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 15.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Limited to 30 visits per year combined for Physical Therapy, Occupational Therapy and Manipulative Treatment; 30 visits per year for Speech Therapy; 30 visits per year combined for Cardiac Rehabilitation Therapy and Pulmonary Rehabilitation Therapy. Visit limits for physical, occupational and speech therapies do not apply for Autism Spectrum Disorder. |
YES | 15.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 15.00% |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Days per Month Members can obtain a 1 month supply through network pharmacies or home delivery. Members also have the option to receive a 3 month supply through network pharmacy or home delivery. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | $40.00 |
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
Cost sharing for Virtual Primary Care matches in-person office visit. |
YES | No Charge |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 15.00% |
100.00% |
| Radiation
|
YES | 15.00% |
100.00% |
| Reconstructive Surgery
|
YES | 15.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Limited to 30 visits per year combined for Physical Therapy, Occupational Therapy and Manipulative Treatment. |
YES | 15.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year |
YES | 15.00% |
100.00% |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year 1,000 annual benefit maximum includes all Dental Services (Routine, Basic and Major) for Adults; Excluded from In-Network Deductible and Out-of-Pocket Limit |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Year Benefit also includes 1 pair of eyeglasses or contact lenses every 12 months. Eyeglass lenses have a $25 copay and frames are covered up to $150. Formulary contact lenses are covered in lieu of glasses with a $25 copay. |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
Covered as medically necessary for the prevention of complications associated with metabolic, neurologic, or peripheral vascular disease |
NO | ||
| Skilled Nursing Facility
Limit: 45.0 Days per Year Limit of 45 days will be any combination of Skilled Nursing Facility or Inpatient Rehabilitation Facility Services. |
YES | 15.00% |
100.00% |
| Specialist Visit
|
YES | $15.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Days per Month Specialty medications are limited to a 1-month supply. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | 50.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 15.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge |
100.00% |
| Transplant
|
YES | 15.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 15.00% |
100.00% |
| Urgent Care Centers or Facilities
$0 Virtual Urgent Care visits are available through vendor. See SBC for additional cost share details for in-person urgent care visits. |
YES | $50.00 |
100.00% |
| Weight Loss Programs
|
YES | 15.00% |
100.00% |
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 15.00% |
100.00% |
UHC Silver-C Value+ (Dental + Vision, No Referrals) Health Insurance Plan Variant 71667MI0050004-06 Attributes
| Plan Attribute | Value |
|---|---|
| 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 |
| EHB Percent of Total Premium | 0.95839995 |
| First Tier Utilization | 100% |
| Formulary ID | MIF030 |
| Formulary URL | URL |
| HIOS Product ID | 71667MI005 |
| Import Date | 2024-08-15 20:01:43 |
| 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 Actuarial Value | 94.17% |
| Issuer ID | 71667 |
| Issuer Marketplace Marketing Name | UnitedHealthcare |
| 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 | MIN011 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area. The Network Area may include select Network providers located in a neighboring state. The plan also covers emergency health care services received outside the service area. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 71667MI0050004-06 |
| Plan Level Exclusions | Some exclusions may apply. See the applicable Certificate of Coverage for details. |
| Plan Marketing Name | UHC Silver Value+ (Dental + Vision, No Referrals) |
| Plan Type | HMO |
| Plan Variant Marketing Name | UHC Silver-C Value+ (Dental + Vision, No Referrals) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,500 |
| SBC Scenario, Having a Baby, Copayment | $40 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $20 |
| SBC Scenario, Having Diabetes, Copayment | $50 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $800 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MIS011 |
| Source Name | SERFF |
| Plan ID | 71667MI0050004 |
| State Code | MI |
| 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 | 15.00% |
| 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 | $3200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $1600 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $1,600 |
| 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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of UHC Silver Value+ (Dental + Vision, No Referrals) Health Insurance Plan, 71667MI0050004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about UHC Silver Value+ (Dental + Vision, No Referrals), 71667MI0050004 Health Insurance Plan, 71667MI0050004
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Does UHC Silver Value+ (Dental + Vision, No Referrals) Health Insurance Plan, 71667MI0050004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (71667MI0050004) Health Insurance Plan, Variant (71667MI0050004-06) have Out Of Country Coverage?
Does (71667MI0050004) Health Insurance Plan, Variant (71667MI0050004-06) have Out of Service Area Coverage?
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