Covenant PHP Exclusive Gold 2000 - 60829MI0190038 Health Insurance Plan
Physicians Health Plan health insurance plan with the Plan ID 60829MI0190038. The plan is called Covenant PHP Exclusive Gold 2000.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 79.20% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 20.80% 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 78.91% (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 21.09% 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 | 60829MI0190038 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Physicians Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 60829MI0190038-00 | ||||||||||||||||||
| 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 - 60829MI0190038-00 Standard On Exchange Plan - 60829MI0190038-01 |
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| Last Plan Update Date | Fri, 09 Sep 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Covenant PHP Exclusive Gold 2000 Health Insurance Plan, 60829MI0190038-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Approval required prior to follow-up care |
YES | $60.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Autism Spectrum Disorders
Prior approval required |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime Prior approval required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year |
YES | $30.00 Copay after deductible |
100.00% |
| Clinical Trials
Prior approval required |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Approval required if stay is longer than federal minimum time frames. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dental Anesthesia
Exclusions: Routine Dental procedures not covered Prior approval required |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Certain DME items require prior approval. Please call PHP. |
YES | 50.00% |
100.00% |
| Emergency Room Services
Emergency Department visits are always covered at network benefit level. Approval required if admitted as inpatient. |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Emergency ambulance services are always covered at network benefit level. |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
Prior approval required |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
|
YES | $20.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Yearly limits: PT and OT: 30 visits, Speech: 30 visits. |
YES | $60.00 Copay after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Prior approval required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Limit: 45.0 Days per Year Exclusions: Custodial care. Private duty nursing services are covered services only when provided coverage includes hospice care in a facility and home. Hospice facility services are limited to 45 days per contract year. Prior approval required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $150.00 Copay after deductible |
100.00% |
| Infertility Treatment
Exclusions: Services and treatment to conceive a pregnancy are excluded. Underlying causes only. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
Prior approval required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Prior approval required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Prior approval required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Prior approval required for all non-routine services. |
YES | $30.00 |
100.00% |
| Mental Health - Intermediate
Prior approval required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $80.00 |
100.00% |
| Non-Preferred Specialty Drugs
Prior approval required on selected drugs. All specialty drugs are only available in up to 31-day supply from CVS mail-order specialty pharmacy. |
YES | 40.00% |
100.00% |
| Nutritional Counseling
Prior approval required. |
YES | 30.00% Coinsurance after deductible |
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)
Exclusions: Elective abortion as defined by the State of Michigan is excluded. Female surgical sterilization is covered with no cost share if using network providers. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year PT/OT - combined visits per contract year; 30 ST per contract year; 30 cardiac/pulmonary visits per contract year. |
YES | $60.00 Copay after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: Elective abortion as defined by the State of Michigan is excluded. Female surgical sterilization is covered with no cost share if using network providers. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $60.00 |
100.00% |
| Preferred Generic Drugs
Tier 1A preferred generic drugs have the lowest copay (see SBC) and are available from a network retail pharmacy in up to a 90-day supply |
YES | $5.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Prior approval required if cost over $1,000. |
YES | 50.00% |
100.00% |
| Radiation
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Prior approval required |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year |
YES | $60.00 Copay after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Prior approval required. |
YES | $60.00 Copay 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
|
NO | ||
| Skilled Nursing Facility
Limit: 45.0 Days per Year Exclusions: Custodial care, private duty nursing Prior approval required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
Prior approval required on selected drugs. All specialty drugs are only available in up to 31-day supply from CVS mail-order specialty pharmacy. |
YES | 20.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
Prior approval required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Prior approval required for all non-routine services. |
YES | $30.00 |
100.00% |
| Substance Use Disorders - Intermediate
Prior approval required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Telemedicine Services
|
YES | $30.00 |
100.00% |
| Transplant
Must be done at Designated Facility. Prior approval required. |
YES | 30.00% 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. Prior approval required |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
Urgent care center visits are always covered at network benefit level. |
YES | $75.00 |
$75.00 |
| Weight Loss Programs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 30.00% Coinsurance after deductible |
100.00% |
Covenant PHP Exclusive Gold 2000 30% Health Insurance Plan Variant 60829MI0190038-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.789090238 |
| 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 |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | MIF005 |
| Formulary URL | URL |
| HIOS Product ID | 60829MI019 |
| Import Date | 9/9/2022 20:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | 0 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 79.20% |
| Issuer ID | 60829 |
| Issuer Marketplace Marketing Name | Physicians Health Plan |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $4000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $2000 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MIN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Coverage for emergency and urgent care only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Coverage only for emergency health services and urgent care center visits at network benefit level |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 60829MI0190038-00 |
| Plan Marketing Name | Covenant PHP Exclusive Gold 2000 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Covenant PHP Exclusive Gold 2000 30% |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,100 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,600 |
| SBC Scenario, Having Diabetes, Deductible | $400 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MIS004 |
| Source Name | SERFF |
| Plan ID | 60829MI0190038 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $13600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,800 |
| 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 Covenant PHP Exclusive Gold 2000 Health Insurance Plan, 60829MI0190038
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Covenant PHP Exclusive Gold 2000, 60829MI0190038 Health Insurance Plan, 60829MI0190038
-
Does Covenant PHP Exclusive Gold 2000 Health Insurance Plan, 60829MI0190038 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (60829MI0190038) Health Insurance Plan, Variant (60829MI0190038-00) offer Disease Management Programs?
Does (60829MI0190038) Health Insurance Plan, Variant (60829MI0190038-00) have Out Of Country Coverage?
Does (60829MI0190038) Health Insurance Plan, Variant (60829MI0190038-00) have Out of Service Area Coverage?
Does (60829MI0190038) Health Insurance Plan, Variant (60829MI0190038-00) offer Disease Management Programs?
Does Covenant PHP Exclusive Gold 2000 30% Health Insurance Plan, Variant (60829MI0190038-00) offer Disease Management Programs for Asthma?
Does Covenant PHP Exclusive Gold 2000 30% Health Insurance Plan, Variant (60829MI0190038-00) offer Disease Management Programs for Diabetes?
Does Covenant PHP Exclusive Gold 2000 30% Health Insurance Plan, Variant (60829MI0190038-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Covenant PHP Exclusive Gold 2000 30% Health Insurance Plan, Variant (60829MI0190038-00) offer Disease Management Programs for Low back pain?
Does Covenant PHP Exclusive Gold 2000 30% Health Insurance Plan, Variant (60829MI0190038-00) offer Disease Management Programs for Pregnancy?
Does Covenant PHP Exclusive Gold 2000 30% Health Insurance Plan, Variant (60829MI0190038-00) offer Disease Management Programs for Weight loss programs?
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