Complete VALUE Silver - 87226TX0060006 Health Insurance Plan
Superior Health Plan health insurance plan with the Plan ID 87226TX0060006. The plan is called Complete VALUE Silver.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.18% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.82% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 87226TX0060006 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | Superior Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 87226TX0060006-00 | ||||||||||||||||||
| Provider Network(s) | ['TXN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 87226TX0060006-00 Standard On Exchange Plan - 87226TX0060006-01 Open to Indians below 300% FPL - 87226TX0060006-02 Open to Indians above 300% FPL - 87226TX0060006-03 73% AV Silver Plan - 87226TX0060006-04 |
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| Last Plan Update Date | Thu, 26 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Benefits of Complete VALUE Silver Health Insurance Plan, 87226TX0060006-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $60.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
YES | $60.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $60.00 |
100.00% |
| Dialysis
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. |
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | 40.00% 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 | $18.20 |
100.00% |
| Habilitation Services
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. Note: This visit limit does not apply when treatment is provided for a mental health/substance use disorder diagnosis or developmental delays. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Coverage includes Cochlear Implants and Bone Anchored Hearing Aids. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Cost share is based on place of service. |
YES | 40.00% 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). |
NO | ||
| Infusion Therapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Cost share is based on place of service. |
YES | $30.00 |
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 | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Mental/Behavioral Health Emergency Transportation/Ambulance
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Mental/Behavioral Health ER Physician Fee
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Mental/Behavioral Health Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $30.00 |
100.00% |
| Mental/Behavioral Health Urgent Care
|
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | $60.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $55.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $30.00 |
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. |
YES | $30.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
Prior authorization may be required. Covered no limit. |
YES | $60.00 |
100.00% |
| Skilled Nursing Facility
Limit: 25.0 Visit(s) per Year |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
100.00% |
| Substance Use Disorder Emergency Room
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Substance Use Disorder Emergency Transportation/Ambulance
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Substance Use Disorder ER Physician Fee
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Substance Use Disorder Outpatient Other Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Use Disorder Urgent Care
|
YES | $30.00 |
100.00% |
| Transplant
Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $60.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Cost share is based on place of service. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Complete VALUE Silver Health Insurance Plan Variant 87226TX0060006-00 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 | Standard Silver 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 | TXF005 |
| Formulary URL | URL |
| HIOS Product ID | 87226TX006 |
| Import Date | 1/26/2023 1:01 |
| 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? | Yes |
| Issuer Actuarial Value | 71.18% |
| Issuer ID | 87226 |
| Issuer Marketplace Marketing Name | Ambetter from Superior HealthPlan |
| 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 | TXN001 |
| 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) | 87226TX0060006-00 |
| Plan Marketing Name | Complete VALUE Silver |
| Plan Type | HMO |
| Plan Variant Marketing Name | Complete VALUE Silver |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,100 |
| SBC Scenario, Having a Baby, Copayment | $400 |
| SBC Scenario, Having a Baby, Deductible | $6,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,300 |
| SBC Scenario, Having Diabetes, Deductible | $800 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TXS002 |
| Source Name | HIOS |
| Specialist Requiring a Referral | All except for mental or behavioral health services, obstetrical or gynecological treatment. |
| Plan ID | 87226TX0060006 |
| State Code | TX |
| 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 | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $12000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,000 |
| 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 | $17000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,500 |
| 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 VALUE Silver Health Insurance Plan, 87226TX0060006
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Complete VALUE Silver, 87226TX0060006 Health Insurance Plan, 87226TX0060006
-
Does Complete VALUE Silver Health Insurance Plan, 87226TX0060006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (87226TX0060006) Health Insurance Plan, Variant (87226TX0060006-00) offer Disease Management Programs?
Does (87226TX0060006) Health Insurance Plan, Variant (87226TX0060006-00) have Out Of Country Coverage?
Does (87226TX0060006) Health Insurance Plan, Variant (87226TX0060006-00) have Out of Service Area Coverage?
Does (87226TX0060006) Health Insurance Plan, Variant (87226TX0060006-00) offer Disease Management Programs?
Does Complete VALUE Silver Health Insurance Plan, Variant (87226TX0060006-00) offer Disease Management Programs for Asthma?
Does Complete VALUE Silver Health Insurance Plan, Variant (87226TX0060006-00) offer Disease Management Programs for Heart disease?
Does Complete VALUE Silver Health Insurance Plan, Variant (87226TX0060006-00) offer Disease Management Programs for Diabetes?
Does Complete VALUE Silver Health Insurance Plan, Variant (87226TX0060006-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 30 Apr 2024 06:06 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