Everyday Bronze with Walgreens + Vision + Adult Dental - 90714MS0030010 Health Insurance Plan

Ambetter of Magnolia Inc. health insurance plan with the Plan ID 90714MS0030010. The plan is called Everyday Bronze with Walgreens + Vision + Adult Dental.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.68% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.32% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 90714MS0030010
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 90714MS0030010-01
Provider Network(s) ['MSN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT).

Providers Mississippi All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 90714MS0030010-00

Standard On Exchange Plan - 90714MS0030010-01

Open to Indians below 300% FPL - 90714MS0030010-02

Open to Indians above 300% FPL - 90714MS0030010-03

Last Plan Update Date Fri, 24 Feb 2023 00:00 GMT
Last Import Date Tue, 22 Oct 2024 06:47 GMT

Benefits of Everyday Bronze with Walgreens + Vision + Adult Dental Health Insurance Plan, 90714MS0030010-01

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

50.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

$90.00

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

YES

50.00%

50.00%
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

50.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

50.00% Coinsurance after deductible

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

$90.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

50.00% Coinsurance after deductible

100.00%
Dental Anesthesia
YES

50.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Care Management
YES

$90.00

100.00%
Diabetes Education
YES

$90.00

100.00%
Dialysis
YES

50.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

50.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Eyeglasses for Adults

Limit: 1.0 Item(s) per Year

Covered up to $130

YES

No Charge

100.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

No Charge

100.00%
Gender Affirming Care
YES

50.00% 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

$27.00

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

50.00% Coinsurance after deductible

100.00%
Hearing Aids

Includes Hearing Aids, Cochelar Implants and Bone Anchored Hearing Aids

NO
Home Health Care Services
YES

50.00% Coinsurance after deductible

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

50.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)

Cost share is based on place of service.

YES

50.00% 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

50.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

50.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Inpatient Rehabilitation

Limit: 30.0 Days per Year

YES

50.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services

Cost share is based on place of service.

YES

$50.00

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

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

YES

50.00%

50.00%
Major Dental Care - Child
NO
Mental/Behavioral Health Emergency Room
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Emergency Transportation/Ambulance
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health ER Physician Fee
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Other Services
YES

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$40.00

100.00%
Mental/Behavioral Health Urgent Care
YES

$40.00

100.00%
Mental Health Other
YES

$40.00

100.00%
Non-Preferred Brand Drugs
YES

50.00% Coinsurance after deductible

100.00%
Nutritional Counseling

For treatment of Diabetes Mellitus and Maternity.

NO
Off Label Prescription Drugs
YES

50.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$40.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

50.00% Coinsurance after deductible

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

50.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

50.00% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care
YES

$40.00

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

$40.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

50.00% Coinsurance after deductible

100.00%
Radiation
YES

50.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

50.00% Coinsurance after deductible

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

50.00% Coinsurance after deductible

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

50.00% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

YES

No Charge

No Charge
Routine Eye Exam (Adult)

Limit: 1.0 Exam(s) per Year

YES

No Charge

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Benefit Period

YES

No Charge

100.00%
Routine Foot Care

Prior authorization may be required. Covered no limit.

YES

$90.00

100.00%
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

50.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$90.00

100.00%
Specialty Drugs
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$40.00

100.00%
Substance Use Disorder Emergency Room
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Use Disorder Emergency Transportation/Ambulance
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Use Disorder ER Physician Fee
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Use Disorder Outpatient Other Services
YES

50.00% Coinsurance after deductible

100.00%
Substance Use Disorder Urgent Care
YES

$40.00

100.00%
Transplant

Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.

YES

50.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Limit: 2.0 Procedure(s) per Year

YES

50.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$50.00

100.00%
Weight Loss Programs
NO
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

50.00% Coinsurance after deductible

100.00%

Everyday Bronze with Walgreens + Vision + Adult Dental Health Insurance Plan Variant 90714MS0030010-01 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 Bronze On Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 0.9581
First Tier Utilization 100%
Formulary ID MSF002
Formulary URL URL
HIOS Product ID 90714MS003
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 Existing
Notice Required for Pregnancy Yes
Is a Referral Required for Specialist? No
Issuer Actuarial Value 64.68%
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 Expanded Bronze
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) 90714MS0030010-01
Plan Marketing Name Everyday Bronze with Walgreens + Vision + Adult Dental
Plan Type HMO
Plan Variant Marketing Name Everyday Bronze with Walgreens + Vision + Adult Dental
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $600
SBC Scenario, Having a Baby, Deductible $8,100
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $800
SBC Scenario, Having Diabetes, Deductible $3,900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID MSS001
Source Name HIOS
Plan ID 90714MS0030010
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 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $16600 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $8300 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $8,300
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 $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
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 Everyday Bronze with Walgreens + Vision + Adult Dental Health Insurance Plan, 90714MS0030010

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Everyday Bronze with Walgreens + Vision + Adult Dental, 90714MS0030010 Health Insurance Plan, 90714MS0030010

  • Does Everyday Bronze with Walgreens + Vision + Adult Dental Health Insurance Plan, 90714MS0030010 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (90714MS0030010) Health Insurance Plan, Variant (90714MS0030010-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does (90714MS0030010) Health Insurance Plan, Variant (90714MS0030010-01) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (90714MS0030010) Health Insurance Plan, Variant (90714MS0030010-01) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

    Does (90714MS0030010) Health Insurance Plan, Variant (90714MS0030010-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does Everyday Bronze with Walgreens + Vision + Adult Dental Health Insurance Plan, Variant (90714MS0030010-01) offer Disease Management Programs for Asthma?

    Yes, the Everyday Bronze with Walgreens + Vision + Adult Dental Health Insurance Plan Variant 90714MS0030010-01 offers Disease Management Program for Asthma.

    Does Everyday Bronze with Walgreens + Vision + Adult Dental Health Insurance Plan, Variant (90714MS0030010-01) offer Disease Management Programs for Heart disease?

    Yes, the Everyday Bronze with Walgreens + Vision + Adult Dental Health Insurance Plan Variant 90714MS0030010-01 offers Disease Management Program for Heart disease.

    Does Everyday Bronze with Walgreens + Vision + Adult Dental Health Insurance Plan, Variant (90714MS0030010-01) offer Disease Management Programs for Diabetes?

    Yes, the Everyday Bronze with Walgreens + Vision + Adult Dental Health Insurance Plan Variant 90714MS0030010-01 offers Disease Management Program for Diabetes.

    Does Everyday Bronze with Walgreens + Vision + Adult Dental Health Insurance Plan, Variant (90714MS0030010-01) offer Disease Management Programs for Pregnancy?

    Yes, the Everyday Bronze with Walgreens + Vision + Adult Dental Health Insurance Plan Variant 90714MS0030010-01 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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