Clear Silver with Walgreens + Vision + Adult Dental - 90714MS0030062 Health Insurance Plan
Ambetter of Magnolia Inc. health insurance plan with the Plan ID 90714MS0030062. The plan is called Clear Silver with Walgreens + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 73.96% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 26.04% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 90714MS0030062 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Mississippi | ||||||||||||||||||
| Health Insurance Issuer | Ambetter of Magnolia Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 90714MS0030062-04 | ||||||||||||||||||
| Provider Network(s) | ['MSN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 90714MS0030062-00 Standard On Exchange Plan - 90714MS0030062-01 Open to Indians below 300% FPL - 90714MS0030062-02 Open to Indians above 300% FPL - 90714MS0030062-03 73% AV Silver Plan - 90714MS0030062-04 |
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| Last Plan Update Date | Fri, 24 Feb 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
Benefits of Clear Silver with Walgreens + Vision + Adult Dental Health Insurance Plan, 90714MS0030062-04
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
50.00% |
| Basic Dental Care - Child
|
NO | ||
| Cardiac Rehabilitation
Limit: 36.0 Visit(s) per Year Limited to: 36 visits per year for cardiac rehabilitation, 20 visits per year for speech therapy and 20 combined visits per year for chiropractic care, occupational and physical therapy. |
YES | No Charge after deductible |
100.00% |
| Chemotherapy
|
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Limited to: 36 visits per year for cardiac rehabilitation, 20 visits per year for speech therapy and 20 combined visits per year for chiropractic care, occupational and physical therapy. |
YES | No Charge after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
100.00% |
| Dental Anesthesia
|
YES | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | No Charge after deductible |
100.00% |
| Diabetes Education
|
YES | No Charge after deductible |
100.00% |
| Dialysis
|
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
|
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | No Charge after deductible |
No Charge after deductible |
| Eyeglasses for Adults
Limit: 1.0 Item(s) per Year Covered up to $130 |
YES | No Charge |
100.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | No Charge after deductible |
100.00% |
| Generic Drugs
Most Ambetter Plans offer Preferred Generic Drugs at $5 or less. Please see plan's Summary of Benefits and Coverage (SBC) or policy document for Preferred Generic and Generic prescription drug cost. |
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year Limited to: 36 visits per year for cardiac rehabilitation, 20 visits per year for speech therapy and 20 combined visits per year for chiropractic care, occupational and physical therapy. |
YES | No Charge after deductible |
100.00% |
| Hearing Aids
Includes Hearing Aids, Cochelar Implants and Bone Anchored Hearing Aids |
NO | ||
| Home Health Care Services
|
YES | No Charge after deductible |
100.00% |
| Hospice Services
Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less. |
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Cost share is based on place of service. |
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
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). |
NO | ||
| Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Inpatient Rehabilitation
Limit: 30.0 Days per Year |
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Cost share is based on place of service. |
YES | No Charge after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
Long Term Acute Care is a covered benefit. Long Term Nursing Care/ Custodial Care is not a covered benefit. |
NO | ||
| Major Dental Care - Adult
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
50.00% |
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Emergency Room
|
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health ER Physician Fee
|
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Inpatient Services
|
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
|
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Urgent Care
|
YES | No Charge after deductible |
100.00% |
| Mental Health Other
|
YES | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
For treatment of Diabetes Mellitus and Maternity. |
NO | ||
| Off Label Prescription Drugs
|
YES | No Charge after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Limited to: 36 visits per year for cardiac rehabilitation, 20 visits per year for speech therapy and 20 combined visits per year for chiropractic care, occupational and physical therapy. |
YES | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Covered in accordance with ACA guidelines. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs. |
YES | No Charge after deductible |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
|
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Limited to: 36 visits per year for cardiac rehabilitation, 20 visits per year for speech therapy and 20 combined visits per year for chiropractic care, occupational and physical therapy. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Limited to: 36 visits per year for cardiac rehabilitation, 20 visits per year for speech therapy and 20 combined visits per year for chiropractic care, occupational and physical therapy. |
YES | No Charge after deductible |
100.00% |
| Routine Dental Services (Adult)
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | No Charge |
No Charge |
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period |
YES | No Charge |
100.00% |
| Routine Foot Care
Prior authorization may be required. Covered no limit. |
YES | No Charge after deductible |
100.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | No Charge after deductible |
100.00% |
| Specialty Drugs
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible |
100.00% |
| Substance Use Disorder Emergency Room
|
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder ER Physician Fee
|
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder Outpatient Other Services
|
YES | No Charge after deductible |
100.00% |
| Substance Use Disorder Urgent Care
|
YES | No Charge after deductible |
100.00% |
| Transplant
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
Limit: 2.0 Procedure(s) per Year |
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Covered in accordance with ACA guidelines. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Cost share is based on place of service. |
YES | No Charge after deductible |
100.00% |
Clear Silver with Walgreens + Vision + Adult Dental Health Insurance Plan Variant 90714MS0030062-04 Attributes
| Plan Attribute | Value |
|---|---|
| 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 | 73% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 0.9581 |
| First Tier Utilization | 100% |
| Formulary ID | MSF007 |
| Formulary URL | URL |
| HIOS Product ID | 90714MS003 |
| Import Date | 2/24/2023 1:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 73.96% |
| Issuer ID | 90714 |
| Issuer Marketplace Marketing Name | Ambetter from Magnolia Health |
| 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 | MSN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 90714MS0030062-04 |
| Plan Marketing Name | Clear Silver with Walgreens + Vision + Adult Dental |
| Plan Type | HMO |
| Plan Variant Marketing Name | Clear Silver with Walgreens + Vision + Adult Dental |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $4,200 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $4,200 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| 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 | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MSS001 |
| Source Name | HIOS |
| Plan ID | 90714MS0030062 |
| 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 |
| 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 | $8400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,200 |
| 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 | $8400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $4200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $4,200 |
| 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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Clear Silver with Walgreens + Vision + Adult Dental Health Insurance Plan, 90714MS0030062
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Clear Silver with Walgreens + Vision + Adult Dental, 90714MS0030062 Health Insurance Plan, 90714MS0030062
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Does Clear Silver with Walgreens + Vision + Adult Dental Health Insurance Plan, 90714MS0030062 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (90714MS0030062) Health Insurance Plan, Variant (90714MS0030062-04) offer Disease Management Programs?
Does (90714MS0030062) Health Insurance Plan, Variant (90714MS0030062-04) have Out Of Country Coverage?
Does (90714MS0030062) Health Insurance Plan, Variant (90714MS0030062-04) have Out of Service Area Coverage?
Does (90714MS0030062) Health Insurance Plan, Variant (90714MS0030062-04) offer Disease Management Programs?
Does Clear Silver with Walgreens + Vision + Adult Dental Health Insurance Plan, Variant (90714MS0030062-04) offer Disease Management Programs for Asthma?
Does Clear Silver with Walgreens + Vision + Adult Dental Health Insurance Plan, Variant (90714MS0030062-04) offer Disease Management Programs for Heart disease?
Does Clear Silver with Walgreens + Vision + Adult Dental Health Insurance Plan, Variant (90714MS0030062-04) offer Disease Management Programs for Diabetes?
Does Clear Silver with Walgreens + Vision + Adult Dental Health Insurance Plan, Variant (90714MS0030062-04) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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