Bronze 4 - 54172FL0010005 Health Insurance Plan

Molina Healthcare of Florida, Inc health insurance plan with the Plan ID 54172FL0010005. The plan is called Bronze 4.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.43% (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 36.57% 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 54172FL0010005
Health Insurance Plan Year 2025
State Florida
Health Insurance Issuer Molina Healthcare of Florida, Inc
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 54172FL0010005-00
Provider Network(s) ['FLN001']
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 Florida 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 - 54172FL0010005-00

Standard On Exchange Plan - 54172FL0010005-01

Open to Indians below 300% FPL - 54172FL0010005-02

Open to Indians above 300% FPL - 54172FL0010005-03

Last Plan Update Date Fri, 11 Oct 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Bronze 4 Health Insurance Plan, 54172FL0010005-00

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

$1,750.00

100.00%
Acupuncture
NO
Allergy Testing
YES

$50.00

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

50.00%

100.00%
Chiropractic Care

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

YES

$50.00

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

$1,500.00

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

No Charge

100.00%
Dialysis
YES

$125.00

100.00%
Durable Medical Equipment
YES

50.00%

100.00%
Emergency Room Services
YES

$1,750.00

$1,750.00
Emergency Transportation/Ambulance
YES

$1,750.00

$1,750.00
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

$25.00

100.00%
Habilitation Services

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

YES

$90.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 20.0 Days per Benefit Period

YES

No Charge

100.00%
Hospice Services
YES

No Charge

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

$1,500.00

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

$1,750.00

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

$1500.00 Copay per Day

100.00%
Inpatient Physician and Surgical Services
YES

$125.00

100.00%
Laboratory Outpatient and Professional Services
YES

$75.00

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

$1500.00 Copay per Day

100.00%
Mental/Behavioral Health Outpatient Services

Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage, Schedule of Benefits, and the Evidence of Coverage for more information on other MH/SUD outpatient services, which may apply a different cost share amount and require Prior Authorization.

YES

$50.00

100.00%
Non-Preferred Brand Drugs
YES

50.00% Coinsurance after deductible

100.00%
Nutritional Counseling

Diabetes coverage includes 'nutrition counseling'; home health services include 'nutritional guidance.'

YES

No Charge

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$50.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

$1,750.00

100.00%
Outpatient Rehabilitation Services

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

YES

$90.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$600.00

100.00%
Preferred Brand Drugs
YES

$125.00 Copay after deductible

100.00%
Prenatal and Postnatal Care
YES

No Charge

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$50.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

50.00%

100.00%
Radiation
YES

$1,750.00

100.00%
Reconstructive Surgery

Only for Breast reconstruction following a Mastectomy.

YES

$125.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

YES

$90.00

100.00%
Rehabilitative Speech Therapy

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

YES

$90.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

No Charge

100.00%
Routine Foot Care
YES

$50.00

100.00%
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

YES

$1500.00 Copay per Day

100.00%
Specialist Visit
YES

$125.00

100.00%
Specialty Drugs
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

$1500.00 Copay per Day

100.00%
Substance Abuse Disorder Outpatient Services

Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage, Schedule of Benefits, and the Evidence of Coverage for more information on other MH/SUD outpatient services, which may apply a different cost share amount and require Prior Authorization.

YES

$50.00

100.00%
Transplant
YES

$125.00

100.00%
Treatment for Temporomandibular Joint Disorders

Limit: 2.0 Procedure(s) per Year

two TMJ procedures per year and one splint per six-month period

YES

$600.00

100.00%
Urgent Care Centers or Facilities
YES

$50.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$150.00

100.00%

Bronze 4 Off Exchange Health Insurance Plan Variant 54172FL0010005-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.6343040190729871
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 Bronze Off Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $6000 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $3000 per person
Drug EHB Deductible, In Network (Tier 1), Individual $3,000
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID FLF003
Formulary URL URL
HIOS Product ID 54172FL001
Import Date 2024-10-11 01:02:00
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 3
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 54172
Issuer Marketplace Marketing Name Molina Healthcare
Market Coverage Individual
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Medical EHB Deductible, In Network (Tier 1), Individual $0
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Metal Level Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID FLN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 54172FL0010005-00
Plan Marketing Name Bronze 4
Plan Type HMO
Plan Variant Marketing Name Bronze 4 Off Exchange
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $2,700
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 $1,800
SBC Scenario, Having Diabetes, Deductible $3,000
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $2,300
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID FLS001
Source Name HIOS
Plan ID 54172FL0010005
State Code FL
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
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $18400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9200 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,200
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 Yes

Copay & Coinsurance of Bronze 4 Health Insurance Plan, 54172FL0010005

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

Frequently Asked Questions(FAQ) about Bronze 4, 54172FL0010005 Health Insurance Plan, 54172FL0010005

  • Does Bronze 4 Health Insurance Plan, 54172FL0010005 support Mail Ordering?

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

  • Does (54172FL0010005) Health Insurance Plan, Variant (54172FL0010005-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs

    Does (54172FL0010005) Health Insurance Plan, Variant (54172FL0010005-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (54172FL0010005) Health Insurance Plan, Variant (54172FL0010005-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

    Does (54172FL0010005) Health Insurance Plan, Variant (54172FL0010005-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs

    Does Bronze 4 Off Exchange Health Insurance Plan, Variant (54172FL0010005-00) offer Disease Management Programs for Asthma?

    Yes, the Bronze 4 Off Exchange Health Insurance Plan Variant 54172FL0010005-00 offers Disease Management Program for Asthma.

    Does Bronze 4 Off Exchange Health Insurance Plan, Variant (54172FL0010005-00) offer Disease Management Programs for Heart disease?

    Yes, the Bronze 4 Off Exchange Health Insurance Plan Variant 54172FL0010005-00 offers Disease Management Program for Heart disease.

    Does Bronze 4 Off Exchange Health Insurance Plan, Variant (54172FL0010005-00) offer Disease Management Programs for Depression?

    Yes, the Bronze 4 Off Exchange Health Insurance Plan Variant 54172FL0010005-00 offers Disease Management Program for Depression.

    Does Bronze 4 Off Exchange Health Insurance Plan, Variant (54172FL0010005-00) offer Disease Management Programs for Diabetes?

    Yes, the Bronze 4 Off Exchange Health Insurance Plan Variant 54172FL0010005-00 offers Disease Management Program for Diabetes.

    Does Bronze 4 Off Exchange Health Insurance Plan, Variant (54172FL0010005-00) offer Disease Management Programs for Pregnancy?

    Yes, the Bronze 4 Off Exchange Health Insurance Plan Variant 54172FL0010005-00 offers Disease Management Program for Pregnancy.

    Does Bronze 4 Off Exchange Health Insurance Plan, Variant (54172FL0010005-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Bronze 4 Off Exchange Health Insurance Plan Variant 54172FL0010005-00 offers Disease Management Program for Weight loss programs.

 

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