CMS Standard Silver with Walgreens - 90714MS0010064 Health Insurance Plan
Ambetter of Magnolia Inc. health insurance plan with the Plan ID 90714MS0010064. The plan is called CMS Standard Silver with Walgreens.
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 | 90714MS0010064 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 90714MS0010064-02 | ||||||||||||||||||
| Provider Network(s) | ['MSN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 14 May 2024 06:16 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 90714MS0010064-00 Standard On Exchange Plan - 90714MS0010064-01 Open to Indians below 300% FPL - 90714MS0010064-02 Open to Indians above 300% FPL - 90714MS0010064-03 73% AV Silver Plan - 90714MS0010064-04 |
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| Last Plan Update Date | Fri, 24 Feb 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 14 May 2024 06:16 GMT |
Benefits of CMS Standard Silver with Walgreens Health Insurance Plan, 90714MS0010064-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $0.00, 0.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $0.00, 0.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| 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 | $0.00, 0.00% |
100.00% |
| Chemotherapy
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | $0.00, 0.00% |
100.00% |
| Dental Anesthesia
|
YES | $0.00, 0.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | $0.00, 0.00% |
100.00% |
| Diabetes Education
|
YES | $0.00, 0.00% |
100.00% |
| Dialysis
|
YES | $0.00, 0.00% |
100.00% |
| Durable Medical Equipment
|
YES | $0.00, 0.00% |
100.00% |
| Emergency Room Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Hearing Aids
Includes Hearing Aids, Cochelar Implants and Bone Anchored Hearing Aids |
NO | ||
| Home Health Care Services
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Cost share is based on place of service. |
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $0.00, 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $0.00, 0.00% |
100.00% |
| Inpatient Rehabilitation
Limit: 30.0 Days per Year |
YES | $0.00, 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
Cost share is based on place of service. |
YES | $0.00, 0.00% |
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
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Emergency Room
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Mental/Behavioral Health Emergency Transportation/Ambulance
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Mental/Behavioral Health ER Physician Fee
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
|
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Urgent Care
|
YES | $0.00, 0.00% |
100.00% |
| Mental Health Other
|
YES | $0.00, 0.00% |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Nutritional Counseling
For treatment of Diabetes Mellitus and Maternity. |
NO | ||
| Off Label Prescription Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00, 0.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $0.00, 0.00% |
100.00% |
| Preferred Brand Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Prenatal and Postnatal Care
|
YES | $0.00, 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
Covered in accordance with ACA guidelines. |
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | $0.00, 0.00% |
100.00% |
| Radiation
|
YES | $0.00, 0.00% |
100.00% |
| Reconstructive Surgery
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period |
YES | $0.00, 0.00% |
100.00% |
| Routine Foot Care
Prior authorization may be required. Covered no limit. |
YES | $0.00, 0.00% |
100.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | $0.00, 0.00% |
100.00% |
| Specialist Visit
|
YES | $0.00, 0.00% |
100.00% |
| Specialty Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Substance Use Disorder Emergency Room
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Substance Use Disorder Emergency Transportation/Ambulance
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Substance Use Disorder ER Physician Fee
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Substance Use Disorder Outpatient Other Services
|
YES | $0.00, 0.00% |
100.00% |
| Substance Use Disorder Urgent Care
|
YES | $0.00, 0.00% |
100.00% |
| Transplant
Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | $0.00, 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Limit: 2.0 Procedure(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $0.00, 0.00% |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Covered in accordance with ACA guidelines. |
YES | $0.00, 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
Cost share is based on place of service. |
YES | $0.00, 0.00% |
100.00% |
CMS Standard Silver with Walgreens Health Insurance Plan Variant 90714MS0010064-02 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 | Design 1 |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | MSF023 |
| Formulary URL | URL |
| HIOS Product ID | 90714MS001 |
| 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 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) | 90714MS0010064-02 |
| Plan Marketing Name | CMS Standard Silver with Walgreens |
| Plan Type | HMO |
| Plan Variant Marketing Name | CMS Standard Silver with Walgreens |
| QHP/Non QHP | Both |
| 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 | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MSS001 |
| Source Name | HIOS |
| Plan ID | 90714MS0010064 |
| 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 | $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, 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), 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 CMS Standard Silver with Walgreens Health Insurance Plan, 90714MS0010064
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about CMS Standard Silver with Walgreens, 90714MS0010064 Health Insurance Plan, 90714MS0010064
-
Does CMS Standard Silver with Walgreens Health Insurance Plan, 90714MS0010064 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (90714MS0010064) Health Insurance Plan, Variant (90714MS0010064-02) offer Disease Management Programs?
Does (90714MS0010064) Health Insurance Plan, Variant (90714MS0010064-02) have Out Of Country Coverage?
Does (90714MS0010064) Health Insurance Plan, Variant (90714MS0010064-02) have Out of Service Area Coverage?
Does (90714MS0010064) Health Insurance Plan, Variant (90714MS0010064-02) offer Disease Management Programs?
Does CMS Standard Silver with Walgreens Health Insurance Plan, Variant (90714MS0010064-02) offer Disease Management Programs for Asthma?
Does CMS Standard Silver with Walgreens Health Insurance Plan, Variant (90714MS0010064-02) offer Disease Management Programs for Heart disease?
Does CMS Standard Silver with Walgreens Health Insurance Plan, Variant (90714MS0010064-02) offer Disease Management Programs for Diabetes?
Does CMS Standard Silver with Walgreens Health Insurance Plan, Variant (90714MS0010064-02) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 14 May 2024 06:16 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