Cox Health Systems Insurance Company health insurance plan with the Plan ID 96384MO0220012. The plan is called Cox HealthPlans Silver Standard $5,000 Deductible.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.01% (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 29.99% 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 | 96384MO0220012 | ||||||||||||||||||
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Health Insurance Plan Year | 2025 | ||||||||||||||||||
State | Missouri | ||||||||||||||||||
Health Insurance Issuer | Cox Health Systems Insurance Company | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 96384MO0220012-00 | ||||||||||||||||||
Provider Network(s) | EPO | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 96384MO0220012-00 Standard On Exchange Plan - 96384MO0220012-01 Open to Indians below 300% FPL - 96384MO0220012-02 Open to Indians above 300% FPL - 96384MO0220012-03 73% AV Silver Plan - 96384MO0220012-04 |
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Last Plan Update Date | Thu, 10 Oct 2024 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 10 Dec 2024 06:32 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
Treatment must begin within 12 months of the injury. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Chemotherapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
Chiropractic visits beyond 26 per benefit period require Prior Authorization. |
YES | 40.00% Coinsurance after deductible |
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
Limit: 1.0 Visit(s) per 6 Months |
YES | 40.00% Coinsurance after deductible |
100.00% |
Diabetes Education
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Dialysis
Covered Services include dialysis treatments in an outpatient dialysis, or home dialysis and training for you and the person who will help you with home self-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
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year Covered lenses and frames each available at limit of one per year. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Gender Affirming Care
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Generic Drugs
|
YES | $20.00 |
100.00% |
Habilitation Services
Limit: 20.0 Visit(s) per Benefit Period Habilitative services definition: 'help you keep, learn or improve skills and functioning for daily living.' |
YES | $40.00 |
100.00% |
Hearing Aids
Benefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period To be eligible for benefits, you must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basis. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Hospice Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
|
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
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
Limit: 2.0 Visit(s) per Benefit Period Out-of-network benefits available include two sessions per year for the purpose of diagnosis or assessment of mental health. |
YES | $40.00 |
100.00% |
Non-Preferred Brand Drugs
|
YES | $80.00 Copay after deductible |
100.00% |
Nutritional Counseling
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Limit: 1.0 Procedure(s) per Lifetime |
YES | 40.00% Coinsurance after deductible |
100.00% |
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $80.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Benefit Period To be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing toward those goals. |
YES | $40.00 |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
|
YES | $40.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | $40.00 |
100.00% |
Private-Duty Nursing
Limit: 82.0 Visit(s) per Benefit Period Private duty nursing services are a Covered Service only when given as part of the 'Home Care Services' benefit. Private Duty Lifetime Maximum: 164 visits In- and Out-of-Network combined. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Prosthetic Devices
Benefits include the purchase, fitting, adjustments, repairs and replacements. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Benefit Period 20 visit limit each for PT and OT. |
YES | $40.00 |
100.00% |
Rehabilitative Speech Therapy
Unlimited visits for speech therapy. |
YES | $40.00 |
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 | 40.00% Coinsurance after deductible |
100.00% |
Routine Foot Care
Coverage is available if Medically Necessary. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Skilled Nursing Facility
Limit: 150.0 Days per Benefit Period Limit is for in-and out-of-network combined and includes rehab and outpatient day rehab. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | $80.00 |
100.00% |
Specialty Drugs
|
YES | $350.00 Copay after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | $40.00 |
100.00% |
Transplant
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | $60.00 |
$60.00 |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.7001186159724491 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2025 |
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 | Design 1 |
EHB Percent of Total Premium | 1.0 |
First Tier Utilization | 100% |
Formulary ID | MOF016 |
Formulary URL | URL |
HIOS Product ID | 96384MO022 |
Import Date | 2024-10-10 01:01:49 |
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 | No |
Is a Referral Required for Specialist? | No |
Issuer ID | 96384 |
Issuer Marketplace Marketing Name | Cox HealthPlans |
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 | MON002 |
Out of Country Coverage | No |
Out of Service Area Coverage | No |
Plan Brochure | URL |
Plan Effective Date | 2025-01-01 |
Plan Expiration Date | 2025-12-31 |
Plan ID (Standard Component ID with Variant) | 96384MO0220012-00 |
Plan Marketing Name | Cox HealthPlans Silver Standard $5,000 Deductible |
Plan Type | EPO |
Plan Variant Marketing Name | Cox HealthPlans Silver Standard $5,000 Deductible |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $3,000 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $5,000 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $1,100 |
SBC Scenario, Having Diabetes, Deductible | $900 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,100 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | MOS002 |
Source Name | HIOS |
Plan ID | 96384MO0220012 |
State Code | MO |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $16000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $8000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $8,000 |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $10000 per group |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $5000 per person |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $5,000 |
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 | $10000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,000 |
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 | $16000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,000 |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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