Clear Silver - 58594MI0030017 Health Insurance Plan
Meridian Health Plan of Michigan, Inc. health insurance plan with the Plan ID 58594MI0030017. The plan is called Clear Silver.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.40% (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 26.60% 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 | 58594MI0030017 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Meridian Health Plan of Michigan, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 58594MI0030017-04 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 Oct 2025 05:27 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 58594MI0030017-00 Standard On Exchange Plan - 58594MI0030017-01 Open to Indians below 300% FPL - 58594MI0030017-02 Open to Indians above 300% FPL - 58594MI0030017-03 73% AV Silver Plan - 58594MI0030017-04 |
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| Last Plan Update Date | Tue, 13 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 Oct 2025 05:27 GMT |
Benefits of Clear Silver Health Insurance Plan, 58594MI0030017-04
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan nan |
YES | $90.00 |
100.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Exclusions: nan Limited to 30 combined visits per year (combined for occupational therapy, physical therapy and chiropractic care). Limited to 30 visits per year speech therapy. Limited to 30 visits per year cardiac therapy. Limited to 30 visits per year pulmonary therapy. |
YES | $90.00 |
100.00% |
| Cosmetic Surgery
Exclusions: nan See Reconstructive Surgery. |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Education
Exclusions: nan nan |
YES | $90.00 |
100.00% |
| Dialysis
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
Exclusions: nan nan |
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
Exclusions: nan Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan nan |
YES | No Charge |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Generic Drugs
Exclusions: nan Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information. |
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Exclusions: nan Limited to 30 combined visits per year (combined for occupational therapy, physical therapy and chiropractic care). Limited to 30 visits per year speech therapy. Limited to 30 visits per year cardiac therapy. Limited to 30 visits per year pulmonary therapy. |
YES | No Charge after deductible |
100.00% |
| Hearing Aids
Exclusions: nan Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit. |
NO | ||
| Home Health Care Services
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Hospice Services
Exclusions: nan Respite Care is covered as part of hospice services only. |
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
Exclusions: nan Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). |
YES | No Charge after deductible |
100.00% |
| Infusion Therapy
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | $25.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit. |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Emergency Room
Exclusions: nan nan |
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Emergency Transportation/Ambulance
Exclusions: nan Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health ER Physician Fee
Exclusions: nan nan |
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Inpatient Services
Exclusions: nan Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. |
YES | $45.00 |
100.00% |
| Mental/Behavioral Health Urgent Care
Exclusions: nan nan |
YES | $45.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
Limit: 6.0 Visit(s) per Year Exclusions: nan Weight loss programs under the supervision of a physician & obesity counseling. |
YES | $90.00 |
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 | $45.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Exclusions: nan Limited to 30 combined visits per year (combined for occupational therapy, physical therapy and chiropractic care). Limited to 30 visits per year speech therapy. Limited to 30 visits per year cardiac therapy. Limited to 30 visits per year pulmonary therapy. |
YES | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | $45.00 |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan Covered in accordance with ACA guidelines. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan Unlimited Virtual 24/7 Care Visits received from Ambetters designated telehealth provider covered at No Charge, except for HSAs. |
YES | $45.00 |
100.00% |
| Private-Duty Nursing
Exclusions: nan nan |
NO | ||
| Prosthetic Devices
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Radiation
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: nan 1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality; 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Exclusions: nan Limited to 30 combined visits per year (combined for occupational therapy, physical therapy and chiropractic care). Limited to 30 visits per year speech therapy. Limited to 30 visits per year cardiac therapy. Limited to 30 visits per year pulmonary therapy. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Exclusions: nan nan |
YES | No Charge after deductible |
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 Year Exclusions: nan nan |
YES | No Charge |
100.00% |
| Routine Foot Care
Exclusions: nan nan |
YES | $90.00 |
100.00% |
| Skilled Nursing Facility
Limit: 45.0 Days per Year Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $90.00 |
100.00% |
| Specialty Drugs
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. |
YES | $45.00 |
100.00% |
| Substance Use Disorder Emergency Room
Exclusions: nan nan |
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder Emergency Transportation/Ambulance
Exclusions: nan Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder ER Physician Fee
Exclusions: nan nan |
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder Outpatient Other Services
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Substance Use Disorder Urgent Care
Exclusions: nan nan |
YES | $45.00 |
100.00% |
| Tier 1b Generic Drugs
Exclusions: nan Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information. |
YES | No Charge after deductible |
100.00% |
| Transplant
Exclusions: nan Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan Coverage includes medical care or services to treat dysfunction or TMJS resulting from a medical cause or injury, office visits for medical evaluation and treatment, X-rays of the temporomandibular joint including contrast studies (but not dental x-rays), and Myofunctional therapy and surgery to the temporomandibular joint: such as condylectomy, meniscectomy, arthrotomy, and arthrocentesis. |
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $45.00 |
100.00% |
| Weight Loss Programs
Exclusions: nan Weight loss programs under the supervision of a physician & obesity counseling. |
YES | $90.00 |
100.00% |
| Well Baby Visits and Care
Exclusions: nan Covered in accordance with ACA guidelines. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
Clear Silver Health Insurance Plan Variant 58594MI0030017-04 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.733950073464012 |
| 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 | 73% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Diabetes, Heart Disease, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | MIF003 |
| Formulary URL | URL |
| HIOS Product ID | 58594MI003 |
| Import Date | 2024-08-13 20:01:38 |
| 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 | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 58594 |
| Issuer Marketplace Marketing Name | Ambetter from Meridian |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MIN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 58594MI0030017-04 |
| Plan Marketing Name | Clear Silver |
| Plan Type | HMO |
| Plan Variant Marketing Name | Clear Silver |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $400 |
| SBC Scenario, Having a Baby, Deductible | $5,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $600 |
| SBC Scenario, Having Diabetes, Deductible | $4,300 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MIS001 |
| Source Name | SERFF |
| Plan ID | 58594MI0030017 |
| State Code | MI |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $10900 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5450 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,450 |
| 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 | $10900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5450 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,450 |
| 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 Clear Silver Health Insurance Plan, 58594MI0030017
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Clear Silver, 58594MI0030017 Health Insurance Plan, 58594MI0030017
-
Does Clear Silver Health Insurance Plan, 58594MI0030017 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (58594MI0030017) Health Insurance Plan, Variant (58594MI0030017-04) offer Disease Management Programs?
Does (58594MI0030017) Health Insurance Plan, Variant (58594MI0030017-04) have Out Of Country Coverage?
Does (58594MI0030017) Health Insurance Plan, Variant (58594MI0030017-04) have Out of Service Area Coverage?
Does (58594MI0030017) Health Insurance Plan, Variant (58594MI0030017-04) offer Disease Management Programs?
Does Clear Silver Health Insurance Plan, Variant (58594MI0030017-04) offer Disease Management Programs for Asthma?
Does Clear Silver Health Insurance Plan, Variant (58594MI0030017-04) offer Disease Management Programs for Heart disease?
Does Clear Silver Health Insurance Plan, Variant (58594MI0030017-04) offer Disease Management Programs for Diabetes?
Does Clear Silver Health Insurance Plan, Variant (58594MI0030017-04) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 07 Oct 2025 05:27 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