Bronze 4 - 79975MS0010005 Health Insurance Plan
Molina Healthcare of Mississippi, Inc health insurance plan with the Plan ID 79975MS0010005. 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 | 79975MS0010005 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Mississippi | ||||||||||||||||||
| Health Insurance Issuer | Molina Healthcare of Mississippi, Inc | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 79975MS0010005-01 | ||||||||||||||||||
| Provider Network(s) | ['MSN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 11 Nov 2025 05:33 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 79975MS0010005-00 Standard On Exchange Plan - 79975MS0010005-01 |
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| Last Plan Update Date | Wed, 13 Nov 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 11 Nov 2025 05:33 GMT |
Benefits of Bronze 4 Health Insurance Plan, 79975MS0010005-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: nan nan |
YES | $1,750.00 |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Bariatric Surgery
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan Must be medically necessary. Company may require a treatment plan, outlining the goals of therapy, mode of therapy, and duration of therapy, to be submitted by the provider prior to the initiation of treatment. |
YES | 50.00% |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Exclusions: nan Limited to 20 visits for any combination of chiropractic treatment, physical therapy and occupational therapy. |
YES | $90.00 |
100.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan Separate cost-sharing may apply for professional services. Maximum three days of facility copayments per inpatient admission. |
YES | $1,500.00 |
100.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Education
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Dialysis
Exclusions: nan nan |
YES | $125.00 |
100.00% |
| Durable Medical Equipment
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Emergency Room Services
Exclusions: nan nan |
YES | $1,750.00 |
$1,750.00 |
| Emergency Transportation/Ambulance
Exclusions: nan nan |
YES | $1,750.00 |
$1,750.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Exclusions: nan nan |
YES | No Charge |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
NO | ||
| Generic Drugs
Limit: 30.0 Days per Month Exclusions: nan Coverage is limited to a 30-day supply retail or 90-day supply mail order. |
YES | $25.00 |
100.00% |
| Habilitation Services
Exclusions: nan 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
Exclusions: nan nan |
NO | ||
| Home Health Care Services
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Hospice Services
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | $1,500.00 |
100.00% |
| Infertility Treatment
Exclusions: nan nan |
NO | ||
| Infusion Therapy
Exclusions: nan nan |
YES | $1,750.00 |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | $1500.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | $125.00 |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | $75.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: nan nan |
YES | $1500.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan 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
Limit: 30.0 Days per Month Exclusions: nan Coverage is limited to a 30-day supply retail or 90-day supply mail order. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | $1,750.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 76.0 Visit(s) per Year Exclusions: nan Limited to 36 cardiac rehabilitation visits per year, 20 speech therapy visits per year, and 20 visits for any combination of chiropractic treatment, physical therapy and occupational therapy. |
YES | $90.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | $600.00 |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Days per Month Exclusions: nan Coverage is limited to a 30-day supply retail or 90-day supply mail order. |
YES | $125.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan Covered services must be included in Grade A and B Recommendations of the USPSTF and include all other preventive health services required by PPACA. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Private-Duty Nursing
Exclusions: nan nan |
NO | ||
| Prosthetic Devices
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Radiation
Exclusions: nan Must be medically necessary. Company may require a treatment plan, outlining the goals of therapy, mode of therapy, and duration of therapy, to be submitted by the provider prior to the initiation of treatment. |
YES | $1,750.00 |
100.00% |
| Reconstructive Surgery
Exclusions: nan Plan only outlines benefits for breast reconstruction. Must be medically necessary and related to mastectomy. 2 copay max |
YES | $125.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Exclusions: nan Limited to 20 visits for any combination of chiropractic treatment, physical therapy and occupational therapy. |
YES | $90.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Exclusions: nan nan |
YES | $90.00 |
100.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period Exclusions: nan nan |
YES | No Charge |
100.00% |
| Routine Foot Care
Exclusions: nan Requires a Diabetes diagnosis. |
YES | $50.00 |
100.00% |
| Skilled Nursing Facility
Limit: 30.0 Days per Year Exclusions: nan nan |
YES | $1500.00 Copay per Day |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $125.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Days per Month Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | $1500.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan 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
Exclusions: nan nan |
YES | $125.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan nan |
YES | $600.00 |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan nan |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | $150.00 |
100.00% |
Bronze 4 Health Insurance Plan Variant 79975MS0010005-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.634304019072987 |
| 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 On 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, Depression, Diabetes, Heart Disease, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | MSF003 |
| Formulary URL | URL |
| HIOS Product ID | 79975MS001 |
| Import Date | 2024-11-13 00:02:05 |
| 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 | 79975 |
| 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 | MSN001 |
| 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) | 79975MS0010005-01 |
| Plan Marketing Name | Bronze 4 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Bronze 4 |
| 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 | MSS001 |
| Source Name | HIOS |
| Plan ID | 79975MS0010005 |
| State Code | MS |
| 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, 79975MS0010005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Bronze 4, 79975MS0010005 Health Insurance Plan, 79975MS0010005
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Does Bronze 4 Health Insurance Plan, 79975MS0010005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (79975MS0010005) Health Insurance Plan, Variant (79975MS0010005-01) offer Disease Management Programs?
Does (79975MS0010005) Health Insurance Plan, Variant (79975MS0010005-01) have Out Of Country Coverage?
Does (79975MS0010005) Health Insurance Plan, Variant (79975MS0010005-01) have Out of Service Area Coverage?
Does (79975MS0010005) Health Insurance Plan, Variant (79975MS0010005-01) offer Disease Management Programs?
Does Bronze 4 Health Insurance Plan, Variant (79975MS0010005-01) offer Disease Management Programs for Asthma?
Does Bronze 4 Health Insurance Plan, Variant (79975MS0010005-01) offer Disease Management Programs for Heart disease?
Does Bronze 4 Health Insurance Plan, Variant (79975MS0010005-01) offer Disease Management Programs for Depression?
Does Bronze 4 Health Insurance Plan, Variant (79975MS0010005-01) offer Disease Management Programs for Diabetes?
Does Bronze 4 Health Insurance Plan, Variant (79975MS0010005-01) offer Disease Management Programs for Pregnancy?
Does Bronze 4 Health Insurance Plan, Variant (79975MS0010005-01) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 11 Nov 2025 05:33 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