Blue Cross and Blue Shield of Kansas City health insurance plan with the Plan ID 34762MO0590004. The plan is called Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.46% (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 5.54% 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 | 34762MO0590004 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Missouri | ||||||||||||||||||
Health Insurance Issuer | Blue Cross and Blue Shield of Kansas City | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 34762MO0590004-06 | ||||||||||||||||||
Provider Network(s) | ['MON003'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 14 May 2024 06:16 GMT). |
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Available Variants of the Health Plan | Standard On Exchange Plan - 34762MO0590004-01 Open to Indians below 300% FPL - 34762MO0590004-02 Open to Indians above 300% FPL - 34762MO0590004-03 73% AV Silver Plan - 34762MO0590004-04 |
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Last Plan Update Date | Fri, 06 Jan 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 14 May 2024 06:16 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | 50.00% |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | 50.00% |
100.00% |
Applied Behavior Analysis Based Therapies
Exclusions: Covered services do not include Applied Behavior Analysis services received as part of any Part C early intervention program or provided by any school district. Applied Behavior Analysis does not include cognitive therapies or psychological testing, personality assessment, intellectual assessment, neuropsychological assessment, psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy, family therapy, and long-term counseling as treatment modalities. Covered services are limited to Medically Necessary treatment ordered by the treating physician or psychologist for Covered Persons under the age of 19. Covered services are limited to the diagnosis and treatment when prescribed or ordered for an individual diagnosed with an Autism Spectrum Disorder by a licensed Physician or licensed psychologist. Autism service providers are limited to any person, entity, or group providing diagnostic or treatment services for Autism Spectrum Disorders that are licensed or certified by the state in which services were rendered to provide health care services; or any person who is licensed under Missouri Chapter 377 as a board certified behavior analyst by the behavior analyst certification board or as an assistant board certified behavior analyst. |
YES | 50.00% |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Bone Marrow Testing
|
YES | 50.00% |
100.00% |
Chemotherapy
|
YES | 50.00% |
100.00% |
Chiropractic Care
|
YES | 50.00% |
100.00% |
Clinical Trials
Covered services do not include the investigational item, device, or service itself; items and services provided solely to satisfy data collection and analysis needs that are not used in the direct clinical management of the patient; costs for services clearly inconsistent with widely accepted standards of care for a particular dianosis; and items and services customarily provided by the research sponsors free of charge for any enrollee in the trial |
YES | 50.00% |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% |
100.00% |
Dental Anesthesia
|
YES | 50.00% |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Education
Limit: 1.0 Item(s) per Year |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
Dialysis
|
YES | 50.00% |
100.00% |
Durable Medical Equipment
Limit: 1.0 Item(s) per Year Mastectomy bras are covered up to 4 per Calendar Year. See Plan Documents for more information. |
YES | 50.00% |
100.00% |
Emergency Room Services
|
YES | 50.00% |
50.00% |
Emergency Transportation/Ambulance
|
YES | 50.00% |
50.00% |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year Coverage includes up to 3 pair of lenses and frames or an annual supply of contact lenses in lieu of eyeglasses, per Calendar Year. See Plan Documents for more information. |
YES | No Charge |
100.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
This tier may offer a Preferred "low cost" Generic copay, see the Prescription Drug formulary for more information. |
YES | $5.00 |
100.00% |
Habilitation Services
Limit: 20.0 Visit(s) per Year |
YES | 50.00% |
100.00% |
Hearing Aids
Limit: 1.0 Item(s) per 3 Years |
YES | 50.00% |
100.00% |
Home Health Care Services
Limit: 100.0 Visit(s) per Year Up to 3 educational visits are covered per Calendar Year. See Plan Documents for more information. |
YES | 50.00% |
100.00% |
Hospice Services
|
YES | 50.00% |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | 50.00% |
100.00% |
Inherited Metabolic Disorder - PKU
|
YES | 50.00% |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: Care provided by Children's Mercy is Out of Network and is not covered. See Access to doctors and hospitals to locate participating providers. |
YES | 50.00% |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 50.00% |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | 50.00% |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
NO | ||
Mental/Behavioral Health Inpatient Services
Exclusions: Care provided by Children's Mercy is Out of Network and is not covered. See Access to doctors and hospitals to locate participating providers. |
YES | 50.00% |
100.00% |
Mental/Behavioral Health Outpatient Services
Exclusions: Care provided by Children's Mercy is Out of Network and is not covered. See Access to doctors and hospitals to locate participating providers. You have a $0 copay to telehealth visits with your doctor. Save money and time when you use telehealth. See Plan Documents for more information about other services obtained from other providers in our network. |
YES | 50.00% |
100.00% |
Newborn Services Other
|
YES | 50.00% |
100.00% |
Non-Preferred Brand Drugs
|
YES | $200.00 |
100.00% |
Nutritional Counseling
|
YES | 50.00% |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: Care provided by Children's Mercy is Out of Network and is not covered. See Access to doctors and hospitals to locate participating providers. This Plan offers $0 copay to Spira Care for your doctor's visit, counseling, and any associated lab or x-rays prescribed by a Spira Care physician. You also have a $0 copay to telehealth visits with your doctor. Save money and time when you use telehealth. See Plan Documents for more information about other services obtained from other providers in our network. |
YES | Tier 1: No Charge Tier 2: $10.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: Care provided by Children's Mercy is Out of Network and is not covered. See Access to doctors and hospitals to locate participating providers. |
YES | 50.00% |
100.00% |
Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year |
YES | 50.00% |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% |
100.00% |
Preferred Brand Drugs
|
YES | $50.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | 50.00% |
100.00% |
Preventive Care/Screening/Immunization
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
Exclusions: Care provided by Children's Mercy is Out of Network and is not covered. See Access to doctors and hospitals to locate participating providers. This Plan offers $0 copay to Spira Care for your doctor's visit, counseling, and any associated lab or x-rays prescribed by a Spira Care physician. You also have a $0 copay to telehealth visits with your doctor. Save money and time when you use telehealth. See Plan Documents for more information about other services obtained from other providers in our network. |
YES | Tier 1: No Charge Tier 2: $10.00 |
100.00% |
Private-Duty Nursing
Limit: 100.0 Visit(s) per Year |
YES | 50.00% |
100.00% |
Prosthetic Devices
|
YES | 50.00% |
100.00% |
Radiation
|
YES | 50.00% |
100.00% |
Reconstructive Surgery
|
YES | 50.00% |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year |
YES | 50.00% |
100.00% |
Rehabilitative Speech Therapy
|
YES | 50.00% |
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 | $25.00 |
100.00% |
Routine Foot Care
|
YES | 50.00% |
100.00% |
Skilled Nursing Facility
Limit: 150.0 Visit(s) per Year |
YES | 50.00% |
100.00% |
Specialist Visit
Exclusions: Care provided by Children's Mercy is Out of Network and is not covered. See Access to doctors and hospitals to locate participating providers. You have a $0 copay to telehealth visits with your doctor. Save money and time when you use telehealth. See Plan Documents for more information about other services obtained from other providers in our network. |
YES | $50.00 |
100.00% |
Specialty Drugs
This tier may offer a Preferred Specialty medication copay, see the Prescription Drug formulary for more information. |
YES | $300.00 |
100.00% |
Substance Abuse Disorder Inpatient Services
Exclusions: Care provided by Children's Mercy is Out of Network and is not covered. See Access to doctors and hospitals to locate participating providers. |
YES | 50.00% |
100.00% |
Substance Abuse Disorder Outpatient Services
Exclusions: Care provided by Children's Mercy is Out of Network and is not covered. See Access to doctors and hospitals to locate participating providers. You have a $0 copay to telehealth visits with your doctor. Save money and time when you use telehealth. See Plan Documents for more information about other services obtained from other providers in our network. |
YES | 50.00% |
100.00% |
Transplant
Limit: 60.0 Days per Year |
YES | 50.00% |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% |
100.00% |
Urgent Care Centers or Facilities
Save money and time with BlueKC Virtual Care. You may access virtual care for a $0 copay, 24/7. |
YES | $30.00 |
$30.00 |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
X-rays and Diagnostic Imaging
|
YES | 50.00% |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.944581981 |
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 | 94% AV Level Silver Plan |
Dental Only Plan | No |
Design Type | Not Applicable |
Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 45% |
Formulary ID | MOF011 |
Formulary URL | URL |
HIOS Product ID | 34762MO059 |
Import Date | 1/6/2023 1:01 |
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 | 34762 |
Issuer Marketplace Marketing Name | Blue Cross and Blue Shield of Kansas City |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Silver |
Multiple In Network Tiers | Yes |
National Network | No |
Network ID | MON003 |
Out of Country Coverage | No |
Out of Service Area Coverage | No |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 34762MO0590004-06 |
Plan Level Exclusions | Services received from Out-of-Network Providers except as specified. Services received if there is no obligation for payment or payment has been fully or partially waived. Subject to Prior Auth when approval was not obtained. Not Medically Necessary. Not specifically covered under the Contract. Experimental/Investigative as determined by Us except as provided. Services You are entitled to at no cost for military service related conditions. Losses due in whole or in part to war/any action of war. Court ordered services, including but not limited to examinations, treatment, and genetic testing. Mason Shunt, banding, gastroplasty, intestinal bypass, gastric balloons, stomach stapling, jejunal bypass, wiring of the jaw and services of a similar nature. Hairplasty or hair removal, regardless of reason or diagnosis. Health/dental services resulting from Accidental Injuries arising out of motor vehicle accidents to the extent such services are payable under any expense payment provision (by whatever term used, including benefits mandated by law) of any automobile insurance policy. Except as provided for charges when no direct patient contact is provided including but not limited to Physician team conferences, for missed appointments, for completion of forms or other non-medical charges. Services which are related to complications arising from treatments or services otherwise excluded. Non-prescription enteral feedings and other nutritional and electrolyte supplements. Diagnosis/treatment of impotency, including drugs. Services or supplies received from any provider in a country where any sanction, embargo, etc. would prohibit payment or reimbursement. Sales tax. Services, supplies, equipment or care received in connection with a non-covered service, supply, equipment or care. Services and supplies to the extent they are payable by Medicare. |
Plan Marketing Name | Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care |
Plan Type | EPO |
Plan Variant Marketing Name | Blue KC Choice Silver $0 ded BlueSelect EPO with Spira Care |
QHP/Non QHP | On the Exchange |
SBC Scenario, Having a Baby, Coinsurance | $700 |
SBC Scenario, Having a Baby, Copayment | $50 |
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 | $700 |
SBC Scenario, Having Diabetes, Deductible | $0 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $700 |
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 |
Second Tier Utilization | 55% |
Service Area ID | MOS001 |
Source Name | HIOS |
Plan ID | 34762MO0590004 |
State Code | MO |
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 | 50.00% |
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, In Network (Tier 2), Default Coinsurance | 50.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), 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 | $1400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $700 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $700 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $1400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $700 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $700 |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 14 May 2024 06:16 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