Blue KC Choice Silver 6000 BlueSelect EPO with Spira Care - 94248KS0560011 Health Insurance Plan
Blue Cross and Blue Shield of Kansas City health insurance plan with the Plan ID 94248KS0560011. The plan is called Blue KC Choice Silver 6000 BlueSelect EPO with Spira Care.
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 | 94248KS0560011 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Kansas | ||||||||||||||||||
| 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 | 94248KS0560011-02 | ||||||||||||||||||
| Provider Network(s) | ['KSN003'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 94248KS0560011-01 Open to Indians below 300% FPL - 94248KS0560011-02 Open to Indians above 300% FPL - 94248KS0560011-03 73% AV Silver Plan - 94248KS0560011-04 |
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| Last Plan Update Date | Wed, 17 Aug 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Blue KC Choice Silver 6000 BlueSelect EPO with Spira Care Health Insurance Plan, 94248KS0560011-02
| 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
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 0.00% |
100.00% |
| Chiropractic Care
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Dental Anesthesia
|
YES | Tier 1: 0.00% Tier 2: $0.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
Limit: 1.0 Item(s) per Year One pair of diabetic shoes and up to 3 pairs of inserts are covered for qualified conditions, per year. See Plan Documents for more information. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Diabetes Education
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Dialysis
|
YES | 0.00% |
100.00% |
| Durable Medical Equipment
Limit: 4.0 Item(s) per Year Mastectomy bras are covered up to 4 per Calendar Year. See Plan Documents for more information. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Emergency Room Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
| Eye Glasses for Children
Limit: 3.0 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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Habilitation Services
Speech therapy is limited to 90 visits per calendar year. See Plan Documents for more information. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Up to 3 educational visits are covered per Calendar Year. See Plan Documents for more information. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Hospice Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Infertility Treatment
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Infusion Therapy
|
YES | 0.00% |
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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 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
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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Non-Preferred Brand Drugs
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Nutritional Counseling
|
NO | ||
| Off Label Prescription Drugs
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 90.0 Visit(s) per Year Speech therapy is limited to 90 visits per calendar year. See Plan Documents for more information. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Preferred Brand Drugs
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Prenatal and Postnatal Care
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Prescription Drugs Other
|
YES | 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Private-Duty Nursing
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| 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
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 90.0 Visit(s) per Year Speech therapy is limited to 90 visits per calendar year. See Plan Documents for more information. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Routine Foot Care
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Skilled Nursing Facility
|
NO | ||
| 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 | $0.00, 0.00% |
100.00% |
| Specialty Drugs
This tier may offer a Preferred Specialty medication copay, see the Prescription Drug formulary for more information. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Transplant
|
YES | 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 0.00% |
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 | $0.00, 0.00% |
$0.00, 0.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 0.00% |
100.00% |
Blue KC Choice Silver $0 ded AI/AN BlueSelect EPO with Spira Care Health Insurance Plan Variant 94248KS0560011-02 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 | 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 | KSF011 |
| Formulary URL | URL |
| HIOS Product ID | 94248KS056 |
| Import Date | 8/17/2022 20:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | 0 |
| 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 | 94248 |
| 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 | KSN003 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | We provide limited services outside the United States through Global Core. Such services are limited to emergency services. |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Services are not provided out-of-network, except in an Emergency or other limited situations. If an out-of-network service is covered and provided outside of Our Service Area, such services will be provided at the in-network benefit level. Non-emergency services that are covered out-of-network will not apply to your in-network out-of-pocket maximum. |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 94248KS0560011-02 |
| Plan Level Exclusions | Services received from Out-of-Network Providers except as specified. For 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. For services You are entitled to at no cost for military service related conditions. For losses due in whole or in part to war/any action of war. For court ordered services, including but not limited to examinations, treatment and genetic testing. For Mason Shunt, banding, gastroplasty, intestinal bypass, gastric balloons, stomach stapling, jejunal bypass, wiring of the jaw and services of a similar nature. For hairplasty or hair removal regardless of reason or diagnosis. For health or 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, missed appointments, completion of forms or other non-medical charges. Services which are related to complications arising from treatments/services otherwise excluded. For non-prescription enteral feedings and other nutritional and electrolyte supplements. For any diagnosis or treatment of sexual dysfunction, including drugs and prosthesis. For services/supplies received from any provider in a country where any sanction, embargo, etc would prohibit payment or reimbursement. For sales tax. For services, supplies, equipment or care received in connection with a non-covered service, supply, equipment or care. Services/supplies to the extent they are payable by Medicare. |
| Plan Marketing Name | Blue KC Choice Silver 6000 BlueSelect EPO with Spira Care |
| Plan Type | EPO |
| Plan Variant Marketing Name | Blue KC Choice Silver $0 ded AI/AN BlueSelect EPO with Spira Care |
| QHP/Non QHP | On the Exchange |
| 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 |
| Second Tier Utilization | 55% |
| Service Area ID | KSS001 |
| Source Name | SERFF |
| Plan ID | 94248KS0560011 |
| State Code | KS |
| 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 | $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, In Network (Tier 2), Default Coinsurance | 0.00% |
| 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 | $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), In Network (Tier 2), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), 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 | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Blue KC Choice Silver 6000 BlueSelect EPO with Spira Care Health Insurance Plan, 94248KS0560011
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue KC Choice Silver 6000 BlueSelect EPO with Spira Care, 94248KS0560011 Health Insurance Plan, 94248KS0560011
-
Does Blue KC Choice Silver 6000 BlueSelect EPO with Spira Care Health Insurance Plan, 94248KS0560011 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (94248KS0560011) Health Insurance Plan, Variant (94248KS0560011-02) offer Disease Management Programs?
Does (94248KS0560011) Health Insurance Plan, Variant (94248KS0560011-02) have Out Of Country Coverage?
Does (94248KS0560011) Health Insurance Plan, Variant (94248KS0560011-02) have Out of Service Area Coverage?
Does (94248KS0560011) Health Insurance Plan, Variant (94248KS0560011-02) offer Disease Management Programs?
Does Blue KC Choice Silver $0 ded AI/AN BlueSelect EPO with Spira Care Health Insurance Plan, Variant (94248KS0560011-02) offer Disease Management Programs for Asthma?
Does Blue KC Choice Silver $0 ded AI/AN BlueSelect EPO with Spira Care Health Insurance Plan, Variant (94248KS0560011-02) offer Disease Management Programs for Heart disease?
Does Blue KC Choice Silver $0 ded AI/AN BlueSelect EPO with Spira Care Health Insurance Plan, Variant (94248KS0560011-02) offer Disease Management Programs for Depression?
Does Blue KC Choice Silver $0 ded AI/AN BlueSelect EPO with Spira Care Health Insurance Plan, Variant (94248KS0560011-02) offer Disease Management Programs for Diabetes?
Does Blue KC Choice Silver $0 ded AI/AN BlueSelect EPO with Spira Care Health Insurance Plan, Variant (94248KS0560011-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Blue KC Choice Silver $0 ded AI/AN BlueSelect EPO with Spira Care Health Insurance Plan, Variant (94248KS0560011-02) offer Disease Management Programs 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