Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) - 73751ND0120059 Health Insurance Plan

Medica Health Plans health insurance plan with the Plan ID 73751ND0120059. The plan is called Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers).

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 73751ND0120059
Health Insurance Plan Year 2023
State North Dakota
Health Insurance Issuer Medica Health Plans
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 73751ND0120059-02
Provider Network(s) ['NDN003']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT).

Providers North Dakota All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 73751ND0120059-00

Standard On Exchange Plan - 73751ND0120059-01

Open to Indians below 300% FPL - 73751ND0120059-02

Open to Indians above 300% FPL - 73751ND0120059-03

Last Plan Update Date Thu, 18 Aug 2022 00:00 GMT
Last Import Date Tue, 23 Apr 2024 07:07 GMT

Benefits of Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, 73751ND0120059-02

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

$0.00

100.00%
Acupuncture
NO
Allergy Testing
YES

$0.00

100.00%
Bariatric Surgery

Limit: 1.0 Procedure(s) per Lifetime

YES

$0.00

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

$0.00

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Benefit Period

YES

$0.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

$0.00

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

$0.00

100.00%
Dialysis
YES

$0.00

100.00%
Durable Medical Equipment
YES

$0.00

100.00%
Emergency Room Services
YES

$0.00

$0.00
Emergency Transportation/Ambulance
YES

$0.00

$0.00
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

Frames are limited to one every other benefit period. Lenses are limited to one pair per benefit period.

YES

$0.00

100.00%
Gender Affirming Care
YES

$0.00

100.00%
Generic Drugs
YES

$0.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Benefit Period

YES

$0.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 40.0 Visit(s) per Benefit Period

YES

$0.00

100.00%
Hospice Services
YES

$0.00

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$0.00

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

$0.00

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

$0.00

100.00%
Inpatient Physician and Surgical Services
YES

$0.00

100.00%
Laboratory Outpatient and Professional Services
YES

$0.00

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

$0.00

100.00%
Mental/Behavioral Health Outpatient Services
YES

$0.00

100.00%
Non-Preferred Brand Drugs
YES

$0.00

100.00%
Nutritional Counseling

Limit: 4.0 Visit(s) per Benefit Period

YES

$0.00

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

$0.00

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Benefit Period

YES

$0.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$0.00

100.00%
Preferred Brand Drugs

Prescription insulin will not exceed $25 per prescription unit

YES

$0.00

100.00%
Prenatal and Postnatal Care
YES

$0.00

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
YES

$0.00

100.00%
Radiation
YES

$0.00

100.00%
Reconstructive Surgery
YES

$0.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Year

30-visit limit is for each of PT and OT.

YES

$0.00

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Year

YES

$0.00

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

$0.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Benefit Period

YES

$0.00

100.00%
Specialist Visit
YES

$0.00

100.00%
Specialty Drugs
YES

$0.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

$0.00

100.00%
Substance Abuse Disorder Outpatient Services
YES

$0.00

100.00%
Transplant

Limit: 1.0 Exam(s) per Transplant

One evaluation is allowed per transplant procedure. Services must be performed at a qualified transplant center.

YES

$0.00

100.00%
Treatment for Temporomandibular Joint Disorders

Limit: 2.0 Treatment(s) per Lifetime

Benefits are subject to a Lifetime Maximum of 2 surgical procedures per Member and a Maximum Benefit Allowance of 1 splint per Member per Benefit Period.

YES

$0.00

100.00%
Urgent Care Centers or Facilities
YES

$0.00

$0.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$0.00

100.00%

Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120059-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Zero Cost Sharing Plan Variation
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID NDF030
Formulary URL URL
HIOS Product ID 73751ND012
Import Date 8/18/2022 1:00
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 73751
Issuer Marketplace Marketing Name Medica
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Bronze
Multiple In Network Tiers No
National Network No
Network ID NDN003
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Services
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Services
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 73751ND0120059-02
Plan Marketing Name Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers)
Plan Type HMO
Plan Variant Marketing Name Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers)
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 $60
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 NDS003
Source Name HIOS
Plan ID 73751ND0120059
State Code ND
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $0
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $0
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
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 $0 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $0
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 $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $0
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, 73751ND0120059

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers), 73751ND0120059 Health Insurance Plan, 73751ND0120059

  • Does Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, 73751ND0120059 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (73751ND0120059) Health Insurance Plan, Variant (73751ND0120059-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does (73751ND0120059) Health Insurance Plan, Variant (73751ND0120059-02) have Out Of Country Coverage?

    Yes. Details: Emergency Services

    Does (73751ND0120059) Health Insurance Plan, Variant (73751ND0120059-02) have Out of Service Area Coverage?

    Yes. Details: Emergency Services

    Does (73751ND0120059) Health Insurance Plan, Variant (73751ND0120059-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (73751ND0120059-02) offer Disease Management Programs for Asthma?

    Yes, the Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120059-02 offers Disease Management Program for Asthma.

    Does Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (73751ND0120059-02) offer Disease Management Programs for Heart disease?

    Yes, the Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120059-02 offers Disease Management Program for Heart disease.

    Does Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (73751ND0120059-02) offer Disease Management Programs for Depression?

    Yes, the Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120059-02 offers Disease Management Program for Depression.

    Does Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (73751ND0120059-02) offer Disease Management Programs for Diabetes?

    Yes, the Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120059-02 offers Disease Management Program for Diabetes.

    Does Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (73751ND0120059-02) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120059-02 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (73751ND0120059-02) offer Disease Management Programs for Low back pain?

    Yes, the Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120059-02 offers Disease Management Program for Low back pain.

    Does Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (73751ND0120059-02) offer Disease Management Programs for Pregnancy?

    Yes, the Altru Prime by Medica Bronze Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120059-02 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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