University of Michigan Health Plan HMO Exclusive Gold Standard - 60829MI0190032 Health Insurance Plan
University of Michigan Health Plan health insurance plan with the Plan ID 60829MI0190032. The plan is called University of Michigan Health Plan HMO Exclusive Gold Standard.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (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 21.94% 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 | 60829MI0190032 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 60829MI0190032-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED NETWORK | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 31 Dec 2024 06:15 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 60829MI0190032-00 Standard On Exchange Plan - 60829MI0190032-01 |
||||||||||||||||||
| Last Plan Update Date | Wed, 09 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 31 Dec 2024 06:15 GMT |
Benefits of University of Michigan Health Plan HMO Exclusive Gold Standard Health Insurance Plan, 60829MI0190032-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Approval required prior to follow-up care. |
YES | $60.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Autism Spectrum Disorders
Prior approval required |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime Prior approval required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year |
YES | $30.00 Copay after deductible |
100.00% |
| Clinical Trials
|
YES | 25.00% Coinsurance after deductible |
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 | 25.00% Coinsurance after deductible |
100.00% |
| Dental Anesthesia
Exclusions: Dental procedures not covered Prior approval required |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Certain DME items require prior approval. Please call PHP. |
YES | 50.00% |
100.00% |
| Emergency Room Services
Emergency Department visits are always covered at network benefit level. Approval required if admitted as inpatient. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Emergency ambulance services are always covered at network benefit level. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
Prior approval required. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
|
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Yearly limits: PT and OT: 30 visits, Speech: 30 visits. |
YES | $30.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Prior approval required. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Limit: 45.0 Days per Year Exclusions: Custodial care Coverage includes inpatient and outpatient hospice care. Prior approval required |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Exclusions: Services and treatment to conceive a pregnancy are excluded. Underlying causes only. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
Prior approval required. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Prior approval required. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% 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
Prior approval required. |
YES | 25.00% Coinsurance after deductible |
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 | $30.00 |
100.00% |
| Mental Health Intermediate
Prior approval required |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $60.00 |
100.00% |
| Nutritional Counseling
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: Elective abortion as defined by the State of Michigan is excluded. Female surgical sterilization is covered with no cost share if using network providers. |
YES | 25.00% Coinsurance after deductible |
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 | $30.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: Elective abortion as defined by the State of Michigan is excluded. Female surgical sterilization is covered with no cost share if using network providers. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Prior approval required if cost over $1,000. |
YES | 50.00% |
100.00% |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Prior approval required. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Prior approval required |
YES | $30.00 |
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 Exclusions: Custodial care, private duty nursing Prior approval required. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
|
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Prior approval required. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Prior approval required for non-routine services. |
YES | $30.00 |
100.00% |
| Substance Use Disorders Intermediate
Prior approval required |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Telemedicine
|
YES | $30.00 |
100.00% |
| Transplant
Must be done at Designated Facility. Prior approval required. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Coverage includes medical care or services to treat dysfunction or TMJ 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. Prior approval required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
Urgent care center visits are always covered at network benefit level. |
YES | $45.00 |
$45.00 |
| Weight Loss Programs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
University of Michigan Health Plan HMO Exclusive Gold Standard Health Insurance Plan Variant 60829MI0190032-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7806125763529309 |
| 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 Gold Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| 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 | MIF004 |
| 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 ID | 60829 |
| Issuer Marketplace Marketing Name | University of Michigan Health Plan |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| 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 | No |
| Out of Service Area Coverage Description | Coverage only for emergency health services and urgent care center 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) | 60829MI0190032-00 |
| Plan Marketing Name | University of Michigan Health Plan HMO Exclusive Gold Standard |
| Plan Type | HMO |
| Plan Variant Marketing Name | University of Michigan Health Plan HMO Exclusive Gold Standard |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,700 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $400 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MIS003 |
| Source Name | SERFF |
| Plan ID | 60829MI0190032 |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| 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 | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| 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 | No |
Copay & Coinsurance of University of Michigan Health Plan HMO Exclusive Gold Standard Health Insurance Plan, 60829MI0190032
| 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 Standard, 60829MI0190032 Health Insurance Plan, 60829MI0190032
-
Does University of Michigan Health Plan HMO Exclusive Gold Standard Health Insurance Plan, 60829MI0190032 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (60829MI0190032) Health Insurance Plan, Variant (60829MI0190032-00) offer Disease Management Programs?
Does (60829MI0190032) Health Insurance Plan, Variant (60829MI0190032-00) have Out Of Country Coverage?
Does (60829MI0190032) Health Insurance Plan, Variant (60829MI0190032-00) have Out of Service Area Coverage?
Does (60829MI0190032) Health Insurance Plan, Variant (60829MI0190032-00) offer Disease Management Programs?
Does University of Michigan Health Plan HMO Exclusive Gold Standard Health Insurance Plan, Variant (60829MI0190032-00) offer Disease Management Programs for Asthma?
Does University of Michigan Health Plan HMO Exclusive Gold Standard Health Insurance Plan, Variant (60829MI0190032-00) offer Disease Management Programs for Diabetes?
Does University of Michigan Health Plan HMO Exclusive Gold Standard Health Insurance Plan, Variant (60829MI0190032-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does University of Michigan Health Plan HMO Exclusive Gold Standard Health Insurance Plan, Variant (60829MI0190032-00) offer Disease Management Programs for Low back pain?
Does University of Michigan Health Plan HMO Exclusive Gold Standard Health Insurance Plan, Variant (60829MI0190032-00) offer Disease Management Programs for Pregnancy?
Does University of Michigan Health Plan HMO Exclusive Gold Standard Health Insurance Plan, Variant (60829MI0190032-00) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 31 Dec 2024 06:15 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