Complete Gold - 58594MI0030008 Health Insurance Plan
Meridian Health Plan of Michigan, Inc. health insurance plan with the Plan ID 58594MI0030008. The plan is called Complete Gold.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.50% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.50% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.98% (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 18.02% 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 | 58594MI0030008 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| 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 | 58594MI0030008-00 | ||||||||||||||||||
| Provider Network(s) | ['MIN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 58594MI0030008-00 Standard On Exchange Plan - 58594MI0030008-01 |
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| Last Plan Update Date | Fri, 21 Oct 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Complete Gold Health Insurance Plan, 58594MI0030008-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Covered when deemed part of emergent care, resulting from an emergency situation. |
NO | ||
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $35.00 |
100.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year 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 | $35.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $35.00 |
100.00% |
| Dialysis
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | 20.00% Coinsurance 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 | $13.80 |
100.00% |
| Habilitation Services
Prior authorization may be required. Covered No Limit. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Coverage only available for cochlear implants and bone anchored hearing aids (BAHA). |
NO | ||
| Home Health Care Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Cost share is based on place of service. |
YES | 20.00% Coinsurance 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). |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Cost share is based on place of service. |
YES | $15.00 |
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 | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Mental/Behavioral Health Emergency Transportation/Ambulance
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Mental/Behavioral Health ER Physician Fee
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Mental/Behavioral Health Inpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $15.00 |
100.00% |
| Mental/Behavioral Health Urgent Care
|
YES | $15.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Limit: 6.0 Visit(s) per Year Weight loss programs under the supervision of a physician & obesity counseling |
YES | $35.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $15.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year 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 | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $15.00 |
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 | $15.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year 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 | 20.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
Coverage is limited to diabetes care only. |
NO | ||
| Skilled Nursing Facility
Limit: 45.0 Days per Year |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $35.00 |
100.00% |
| Specialty Drugs
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $15.00 |
100.00% |
| Substance Use Disorder Emergency Room
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Substance Use Disorder Emergency Transportation/Ambulance
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Substance Use Disorder ER Physician Fee
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Substance Use Disorder Outpatient Other Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Substance Use Disorder Urgent Care
|
YES | $15.00 |
100.00% |
| Transplant
Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
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, Myofunctional therapy and Surgery to the temporomandibular joint, such as condylectomy, meniscectomy, arthrotomy, and arthrocentesis. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $35.00 |
100.00% |
| Weight Loss Programs
Weight loss programs under the supervision of a physician & obesity counseling |
YES | $35.00 |
100.00% |
| 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 | 20.00% Coinsurance after deductible |
100.00% |
Complete Gold Health Insurance Plan Variant 58594MI0030008-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.819755517 |
| 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 | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | MIF004 |
| Formulary URL | URL |
| HIOS Product ID | 58594MI003 |
| Import Date | 10/21/2022 20:01 |
| 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 Actuarial Value | 81.50% |
| 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 | Gold |
| 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 | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 58594MI0030008-00 |
| Plan Marketing Name | Complete Gold |
| Plan Type | HMO |
| Plan Variant Marketing Name | Complete Gold |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,500 |
| SBC Scenario, Having a Baby, Copayment | $300 |
| SBC Scenario, Having a Baby, Deductible | $1,450 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $800 |
| SBC Scenario, Having Diabetes, Deductible | $800 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,450 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MIS001 |
| Source Name | SERFF |
| Plan ID | 58594MI0030008 |
| 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 | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $2900 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1450 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,450 |
| 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 | $15000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,500 |
| 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 Complete Gold Health Insurance Plan, 58594MI0030008
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Complete Gold, 58594MI0030008 Health Insurance Plan, 58594MI0030008
-
Does Complete Gold Health Insurance Plan, 58594MI0030008 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (58594MI0030008) Health Insurance Plan, Variant (58594MI0030008-00) offer Disease Management Programs?
Does (58594MI0030008) Health Insurance Plan, Variant (58594MI0030008-00) have Out Of Country Coverage?
Does (58594MI0030008) Health Insurance Plan, Variant (58594MI0030008-00) have Out of Service Area Coverage?
Does (58594MI0030008) Health Insurance Plan, Variant (58594MI0030008-00) offer Disease Management Programs?
Does Complete Gold Health Insurance Plan, Variant (58594MI0030008-00) offer Disease Management Programs for Asthma?
Does Complete Gold Health Insurance Plan, Variant (58594MI0030008-00) offer Disease Management Programs for Heart disease?
Does Complete Gold Health Insurance Plan, Variant (58594MI0030008-00) offer Disease Management Programs for Diabetes?
Does Complete Gold Health Insurance Plan, Variant (58594MI0030008-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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