University of Michigan Health Plan HMO Exclusive Gold Select - 60829MI0190016 Health Insurance Plan
University of Michigan Health Plan health insurance plan with the Plan ID 60829MI0190016. The plan is called University of Michigan Health Plan HMO Exclusive Gold Select.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 100.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 60829MI0190016 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | University of Michigan Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 60829MI0190016-02 | ||||||||||||||||||
| Provider Network(s) | PREFERRED NETWORK | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 Jan 2025 05:50 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 60829MI0190016-00 Standard On Exchange Plan - 60829MI0190016-01 |
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| Last Plan Update Date | Wed, 09 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 Jan 2025 05:50 GMT |
Benefits of University of Michigan Health Plan HMO Exclusive Gold Select Health Insurance Plan, 60829MI0190016-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Prior approval required |
YES | No Charge |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge |
100.00% |
| Autism Spectrum Disorders
Prior approval required |
YES | No Charge |
100.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime Prior approval required |
YES | No Charge |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Clinical Trials
Prior approval required |
YES | No Charge |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Approval required if stay is longer than federal minimum time frames. |
YES | No Charge |
100.00% |
| Dental Anesthesia
Prior approval required |
YES | No Charge |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | No Charge |
100.00% |
| Durable Medical Equipment
Certain DME require Prior Auth. Contact PHP |
YES | No Charge |
100.00% |
| Emergency Room Services
|
YES | No Charge |
No Charge |
| Emergency Transportation/Ambulance
|
YES | No Charge |
No Charge |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
Prior approval required |
YES | No Charge |
100.00% |
| Generic Drugs
|
YES | No Charge |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Yearly limits: PT and OT: 30 visits, Speech: 30 visits. |
YES | No Charge |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Prior approval required |
YES | No Charge |
100.00% |
| Hospice Services
Limit: 45.0 Days per Year Exclusions: Custodial Care Coverage includes inpatient and outpatient hospice care. |
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge |
100.00% |
| Infertility Treatment
Underlying causes only. |
YES | No Charge |
100.00% |
| Infusion Therapy
Prior approval required. |
YES | No Charge |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Prior approval required |
YES | No Charge |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | No Charge |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Prior approval required. |
YES | No Charge |
100.00% |
| Mental/Behavioral Health Outpatient Services
Prior approval required for all non-routine services. The cost sharing that displays applies to outpatient office visits and testing only. All other outpatient services, such as, but not limited to, treatment and therapies, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | No Charge |
100.00% |
| Mental Health Intermediate
Prior approval required |
YES | No Charge |
100.00% |
| Non-Preferred Brand Drugs
|
YES | No Charge |
100.00% |
| Non-Preferred Specialty Drugs
Prior approval required on selected drugs. All specialty drugs are only available in up to 31-day supply from Accredo mail-order specialty pharmacy. |
YES | No Charge |
100.00% |
| Nutritional Counseling
Prior approval required |
YES | No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year PT/OT - combined visits per contract year; 30 ST per contract year; 30 cardiac/pulmonary visits per contract year. |
YES | No Charge |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge |
100.00% |
| Preferred Brand Drugs
|
YES | No Charge |
100.00% |
| Preferred Generic Drugs
Tier 1A preferred generic drugs have the lowest copay (see SBC) and are available from a network retail pharmacy in up to a 90-day supply |
YES | No Charge |
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 | $0.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Prior approval required for some items |
YES | No Charge |
100.00% |
| Radiation
|
YES | No Charge |
100.00% |
| Reconstructive Surgery
Prior approval required |
YES | No Charge |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Prior approval required |
YES | No Charge |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 45.0 Days per Year Prior approval required |
YES | No Charge |
100.00% |
| Specialist Visit
|
YES | $0.00 |
100.00% |
| Specialty Drugs
Prior approval required on select drugs. All specialty drugs are only available in up to 31-day supply from Accredo mail-order specialty pharmacy. |
YES | No Charge |
100.00% |
| Substance Abuse Disorder Inpatient Services
Prior approval required. |
YES | No Charge |
100.00% |
| Substance Abuse Disorder Outpatient Services
Prior approval required for all non-routine services. |
YES | No Charge |
100.00% |
| Substance Abuse Intermediate
Prior approval required |
YES | No Charge |
100.00% |
| Telemedicine Services
Cost share applies per benefit category |
YES | No Charge |
100.00% |
| Transplant
Must be done at Designated Facility. Prior approval required. |
YES | No Charge |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Coverage includes medical care or services to treat dysfunction or TMJS resulting from a medical cause or injury, Office visits for medical evaluation and treatment, X-rays of the temporomandibular joint including contrast studies, but not dental X-rays, Myofunctional therapy and Surgery to the temporomandibular joint, such as condylectomy, meniscectomy, arthrotomy, and arthrocentesis. |
YES | No Charge |
100.00% |
| Urgent Care Centers or Facilities
|
YES | No Charge |
No Charge |
| Weight Loss Programs
|
YES | No Charge |
100.00% |
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge |
100.00% |
University of Michigan Health Plan HMO Exclusive Gold Select Health Insurance Plan Variant 60829MI0190016-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| 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 | Zero Cost Sharing Plan Variation |
| 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 | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | MIF008 |
| Formulary URL | URL |
| HIOS Product ID | 60829MI019 |
| Import Date | 2024-10-09 20:01:46 |
| 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 Actuarial Value | 100.00% |
| Issuer ID | 60829 |
| Issuer Marketplace Marketing Name | University of Michigan Health Plan |
| 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 | 0.00% |
| 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, 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 | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MIN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Coverage for emergency and urgent care only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Coverage only for emergency health services and urgent care visits at network benefit level |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 60829MI0190016-02 |
| Plan Marketing Name | University of Michigan Health Plan HMO Exclusive Gold Select |
| Plan Type | HMO |
| Plan Variant Marketing Name | University of Michigan Health Plan HMO Exclusive Gold Select |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MIS003 |
| Source Name | SERFF |
| Plan ID | 60829MI0190016 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| 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 University of Michigan Health Plan HMO Exclusive Gold Select Health Insurance Plan, 60829MI0190016
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about University of Michigan Health Plan HMO Exclusive Gold Select, 60829MI0190016 Health Insurance Plan, 60829MI0190016
-
Does University of Michigan Health Plan HMO Exclusive Gold Select Health Insurance Plan, 60829MI0190016 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (60829MI0190016) Health Insurance Plan, Variant (60829MI0190016-02) offer Disease Management Programs?
Does (60829MI0190016) Health Insurance Plan, Variant (60829MI0190016-02) have Out Of Country Coverage?
Does (60829MI0190016) Health Insurance Plan, Variant (60829MI0190016-02) have Out of Service Area Coverage?
Does (60829MI0190016) Health Insurance Plan, Variant (60829MI0190016-02) offer Disease Management Programs?
Does University of Michigan Health Plan HMO Exclusive Gold Select Health Insurance Plan, Variant (60829MI0190016-02) offer Disease Management Programs for Asthma?
Does University of Michigan Health Plan HMO Exclusive Gold Select Health Insurance Plan, Variant (60829MI0190016-02) offer Disease Management Programs for Diabetes?
Does University of Michigan Health Plan HMO Exclusive Gold Select Health Insurance Plan, Variant (60829MI0190016-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does University of Michigan Health Plan HMO Exclusive Gold Select Health Insurance Plan, Variant (60829MI0190016-02) offer Disease Management Programs for Low back pain?
Does University of Michigan Health Plan HMO Exclusive Gold Select Health Insurance Plan, Variant (60829MI0190016-02) offer Disease Management Programs for Pregnancy?
Does University of Michigan Health Plan HMO Exclusive Gold Select Health Insurance Plan, Variant (60829MI0190016-02) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 07 Jan 2025 05:50 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