Altru Prime by Medica Gold Standard - 73751ND0120055 Health Insurance Plan

Medica Health Plans health insurance plan with the Plan ID 73751ND0120055. The plan is called Altru Prime by Medica 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 73751ND0120055
Health Insurance Plan Year 2025
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 73751ND0120055-00
Provider Network(s) STANDARDTIER PREFERRED PREFERREDTIER
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers North Dakota All US States
All 6790 147643
PCP 853 14472
Allergy 1 28
OB/GYN 19 397
Dentists 1 19
Available Variants of the Health Plan

Standard Off Exchange Plan - 73751ND0120055-00

Standard On Exchange Plan - 73751ND0120055-01

Open to Indians below 300% FPL - 73751ND0120055-02

Open to Indians above 300% FPL - 73751ND0120055-03

Last Plan Update Date Wed, 25 Sep 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Altru Prime by Medica Gold Standard Health Insurance Plan, 73751ND0120055-00

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

25.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

25.00% Coinsurance after deductible

100.00%
Bariatric Surgery

Limit: 1.0 Procedure(s) per Lifetime

YES

25.00% Coinsurance after deductible

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

$60.00

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Benefit Period

YES

$30.00

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

25.00% Coinsurance after deductible

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

No Charge

100.00%
Dialysis
YES

25.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

25.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

See policy or plan document for additional benefit explanation.

YES

25.00% Coinsurance after deductible

100.00%
Gender Affirming Care
YES

25.00% Coinsurance after deductible

100.00%
Generic Drugs
YES

$15.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Benefit Period

See policy or plan document for additional benefit explanation.

YES

$30.00

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

YES

25.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 40.0 Visit(s) per Benefit Period

See policy or plan document for additional benefit explanation.

YES

25.00% Coinsurance after deductible

100.00%
Hospice Services
YES

25.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)

See policy or plan document for additional benefit explanation.

YES

25.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

25.00% Coinsurance after deductible

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

Exclusions: Routine or chronic dental service not covered

Coverage for diagnosis and treatment of periodontal disease in acute or chronic disease state if recommended by a board-certified medical practitioner based on health-related impacts or on further deterioration in disease state due to gum disease.

NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

25.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$30.00

100.00%
Non-Preferred Brand Drugs
YES

$60.00

100.00%
Nutritional Counseling

Limit: 12.0 Visit(s) per Benefit Period

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)
YES

25.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Benefit Period

See policy or plan document for additional benefit explanation.

YES

$30.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$30.00

100.00%
Prenatal and Postnatal Care
YES

25.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness

Virtual visits are unlimited with a $0 copayment when provided by a designated in-network virtual care provider for non-urgent medical symptoms for common illnesses.

YES

$30.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

25.00% Coinsurance after deductible

100.00%
Radiation
YES

25.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

25.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Year

See policy or plan document for additional benefit explanation.

YES

$30.00

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Year

See policy or plan document for additional benefit explanation.

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 Benefit Period

YES

$30.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Benefit Period

See policy or plan document for additional benefit explanation.

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
YES

25.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$30.00

100.00%
Transplant

Limit: 1.0 Exam(s) per Transplant

See policy or plan document for additional benefit explanation.

YES

25.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Limit: 2.0 Treatment(s) per Lifetime

See policy or plan document for additional benefit explanation.

YES

25.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$45.00

$45.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

25.00% Coinsurance after deductible

100.00%

Altru Prime by Medica Gold Standard Health Insurance Plan Variant 73751ND0120055-00 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, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID NDF001
Formulary URL URL
HIOS Product ID 73751ND012
Import Date 2024-09-25 01:01:35
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 73751
Issuer Marketplace Marketing Name Medica
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 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 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 73751ND0120055-00
Plan Marketing Name Altru Prime by Medica Gold Standard
Plan Type HMO
Plan Variant Marketing Name Altru Prime by Medica Gold Standard
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,400
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $1,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $700
SBC Scenario, Having Diabetes, Deductible $1,100
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $300
SBC Scenario, Treatment of a Simple Fracture, Copayment $100
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID NDS003
Source Name HIOS
Plan ID 73751ND0120055
State Code ND
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 Altru Prime by Medica Gold Standard Health Insurance Plan, 73751ND0120055

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

Frequently Asked Questions(FAQ) about Altru Prime by Medica Gold Standard, 73751ND0120055 Health Insurance Plan, 73751ND0120055

  • Does Altru Prime by Medica Gold Standard Health Insurance Plan, 73751ND0120055 support Mail Ordering?

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

  • Does (73751ND0120055) Health Insurance Plan, Variant (73751ND0120055-00) 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 (73751ND0120055) Health Insurance Plan, Variant (73751ND0120055-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services

    Does (73751ND0120055) Health Insurance Plan, Variant (73751ND0120055-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services

    Does (73751ND0120055) Health Insurance Plan, Variant (73751ND0120055-00) 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 Gold Standard Health Insurance Plan, Variant (73751ND0120055-00) offer Disease Management Programs for Asthma?

    Yes, the Altru Prime by Medica Gold Standard Health Insurance Plan Variant 73751ND0120055-00 offers Disease Management Program for Asthma.

    Does Altru Prime by Medica Gold Standard Health Insurance Plan, Variant (73751ND0120055-00) offer Disease Management Programs for Heart disease?

    Yes, the Altru Prime by Medica Gold Standard Health Insurance Plan Variant 73751ND0120055-00 offers Disease Management Program for Heart disease.

    Does Altru Prime by Medica Gold Standard Health Insurance Plan, Variant (73751ND0120055-00) offer Disease Management Programs for Depression?

    Yes, the Altru Prime by Medica Gold Standard Health Insurance Plan Variant 73751ND0120055-00 offers Disease Management Program for Depression.

    Does Altru Prime by Medica Gold Standard Health Insurance Plan, Variant (73751ND0120055-00) offer Disease Management Programs for Diabetes?

    Yes, the Altru Prime by Medica Gold Standard Health Insurance Plan Variant 73751ND0120055-00 offers Disease Management Program for Diabetes.

    Does Altru Prime by Medica Gold Standard Health Insurance Plan, Variant (73751ND0120055-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Altru Prime by Medica Gold Standard Health Insurance Plan Variant 73751ND0120055-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Altru Prime by Medica Gold Standard Health Insurance Plan, Variant (73751ND0120055-00) offer Disease Management Programs for Low back pain?

    Yes, the Altru Prime by Medica Gold Standard Health Insurance Plan Variant 73751ND0120055-00 offers Disease Management Program for Low back pain.

    Does Altru Prime by Medica Gold Standard Health Insurance Plan, Variant (73751ND0120055-00) offer Disease Management Programs for Pregnancy?

    Yes, the Altru Prime by Medica Gold Standard Health Insurance Plan Variant 73751ND0120055-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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