Market HMO Select Silver - CLE-Care - 99969OH0080432 Health Insurance Plan

Medical Health Insuring Corp. of Ohio health insurance plan with the Plan ID 99969OH0080432. The plan is called Market HMO Select Silver - CLE-Care.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.13% (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 29.87% 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 99969OH0080432
Health Insurance Plan Year 2023
State Ohio
Health Insurance Issuer Medical Health Insuring Corp. of Ohio
Plan Formulary Description URL Formulary URL
Health Insurance Plan Variant 99969OH0080432-01
Provider Network(s) ['OHN006']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 02 Jul 2024 06:38 GMT).

Providers Ohio 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 - 99969OH0080432-00

Standard On Exchange Plan - 99969OH0080432-01

Open to Indians below 300% FPL - 99969OH0080432-02

Open to Indians above 300% FPL - 99969OH0080432-03

73% AV Silver Plan - 99969OH0080432-04

87% AV Silver Plan - 99969OH0080432-05

94% AV Silver Plan - 99969OH0080432-06

Last Plan Update Date Wed, 15 Mar 2023 00:00 GMT
Last Import Date Tue, 02 Jul 2024 06:38 GMT

Benefits of Market HMO Select Silver - CLE-Care Health Insurance Plan, 99969OH0080432-01

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

$200.00

100.00%
Acupuncture
NO
Allergy Testing
YES

$25.00

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

No Charge

100.00%
Chemotherapy
YES

$70.00

100.00%
Chiropractic Care

Limit: 12.0 Visit(s) per Benefit Period

YES

$70.00

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

2 day maximum copay charge

YES

$2,500.00

100.00%
Dental Check-Up for Children
YES

No Charge

100.00%
Diabetes Education
YES

No Charge

100.00%
Dialysis
YES

50.00%

100.00%
Durable Medical Equipment

Cochlear implants are covered. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period.

YES

50.00%

100.00%
Emergency Room Services
YES

$1,000.00

$1,000.00
Emergency Transportation/Ambulance
YES

$1,000.00

$1,000.00
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

50.00%

100.00%
Gender Affirming Care
YES

50.00%

100.00%
Generic Drugs

The Tier 1 copay listed applies only to MetroHealth pharmacies. Generic drugs are copies of brand-name drugs that contain the same active ingredients but are usually less expensive. They also must meet the same strict U.S. Food and Drug Administration (FDA) standards for quality, strength and purity. If you fill a Generic drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual.

YES

Tier 1: $10.00

Tier 2: $25.00

100.00%
Habilitation Services

This includes coverage for those with a medical diagnosis of Autism Spectrum disorder. These limits apply: 20 visits per year for Speech Therapy; 20 visits per year for Occupational Therapy; and 20 visits per year for Physical Therapy.

YES

$70.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 100.0 Visit(s) per Benefit Period

YES

$70.00

100.00%
Hospice Services
YES

50.00%

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$215.00

100.00%
Infertility Treatment

Only diagnostic and exploratory procedures required to diagnose infertility and certain surgical procedures to correct the medically diagnosed disease or condition of the reproductive organs are covered.

YES

50.00%

100.00%
Infusion Therapy
YES

50.00%

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

Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services. Maximum of 2 days for charging an inpatient copay.

YES

$2500.00 Copay per Day

100.00%
Inpatient Physician and Surgical Services

One (1) Inpatient visit per day per Physican or other Professional Provider

YES

$200.00

100.00%
Laboratory Outpatient and Professional Services
YES

$25.00

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

No Charge

100.00%
Mental/Behavioral Health Inpatient Services
YES

$2500.00 Copay per Day

100.00%
Mental/Behavioral Health Outpatient Services
YES

$25.00

100.00%
Non-Preferred Brand Drugs

Non-preferred Brand-name drugs, your third cost-share tier, are included in Medical Mutual?s formulary but are typically more expensive than similar Preferred Brand-name drugs. If you fill a Non-preferred Brand-name drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual.

YES

50.00% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

50.00%

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Medically necessary only

YES

No Charge

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$25.00

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

$1,000.00

100.00%
Outpatient Rehabilitation Services

20 visits for Speech Therapy, 20 visits for Pulmonary Rehabilitation and 36 visits for Cardiac Rehabilitation.? Benefit also includes Physical Medicine and Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services.

YES

$70.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$200.00

100.00%
Preferred Brand Drugs

The Tier 1 copay listed applies only to MetroHealth pharmacies. Preferred Brand-name drugs, your second cost-share tier, are included in Medical Mutual's formulary and are typically less expensive than similar Non-preferred Brand-name drugs. They are safe, effective alternatives to other brand-name drugs that may cost more. If you fill a Preferred Brand-name drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual.

YES

Tier 1: $150.00

Tier 2: $200.00

100.00%
Prenatal and Postnatal Care

2 day maximum copay charge

YES

$2,500.00

100.00%
Preventive Care/Screening/Immunization

Pap test - one per benefit period. Mammogram - one per benefit period.

YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$25.00

100.00%
Private-Duty Nursing

Limit: 90.0 Days per Benefit Period

YES

$70.00

100.00%
Prosthetic Devices
YES

50.00%

100.00%
Radiation
YES

50.00%

100.00%
Reconstructive Surgery
YES

$1,000.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Benefit Period

20 visits for Rehabilitative Occupational Therapy and 20 visits for Rehabilitative Physical Therapy

YES

$70.00

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Benefit Period

YES

$70.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Preventive services only.? See plan certificate for more information.

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 90.0 Days per Benefit Period

2 day maximum copay charge

YES

$2500.00 Copay per Day

100.00%
Specialist Visit
YES

$70.00

100.00%
Specialty Drugs

Specialty drugs must be obtained through a contracted specialty pharmacy, and are limited to a 30-day supply.

YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

$2500.00 Copay per Day

100.00%
Substance Abuse Disorder Outpatient Services
YES

$25.00

100.00%
Transplant

Per Transplant: $30,000 maximum for unrelated donor search. $10,000 maximum for transportation, meals & lodging.

YES

$2,500.00

100.00%
Treatment for Temporomandibular Joint Disorders
YES

50.00%

100.00%
Urgent Care Centers or Facilities
YES

$25.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$70.00

100.00%

Market HMO Select Silver - CLE-Care Health Insurance Plan Variant 99969OH0080432-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.701262953
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 On 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 50.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $8000 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $4000 per person
Drug EHB Deductible, In Network (Tier 1), Individual $4,000
Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 50.00%
Drug EHB Deductible, In Network (Tier 2), Family Per Group $8000 per group
Drug EHB Deductible, In Network (Tier 2), Family Per Person $4000 per person
Drug EHB Deductible, In Network (Tier 2), Individual $4,000
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
EHB Percent of Total Premium 1
First Tier Utilization 25%
Formulary ID OHF014
Formulary URL URL
HIOS Product ID 99969OH008
Import Date 3/15/2023 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 2
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 99969
Issuer Marketplace Marketing Name MedMutual
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 50.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Medical EHB Deductible, In Network (Tier 1), Individual $0
Medical EHB Deductible, In Network (Tier 2), Default Coinsurance 50.00%
Medical EHB Deductible, In Network (Tier 2), Family Per Group $0 per group
Medical EHB Deductible, In Network (Tier 2), Family Per Person $0 per person
Medical EHB Deductible, In Network (Tier 2), Individual $0
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 Silver
Multiple In Network Tiers Yes
National Network No
Network ID OHN006
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Covered as Non-Network
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 99969OH0080432-01
Plan Marketing Name Market HMO Select Silver - CLE-Care
Plan Type HMO
Plan Variant Marketing Name Market HMO Select Silver - CLE-Care
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,300
SBC Scenario, Having a Baby, Copayment $2,700
SBC Scenario, Having a Baby, Deductible $0
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 $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $200
SBC Scenario, Treatment of a Simple Fracture, Copayment $1,000
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 75%
Service Area ID OHS010
Source Name SERFF
Plan ID 99969OH0080432
State Code OH
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 $16500 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8250 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,250
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $16500 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $8250 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $8,250
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 Yes

Copay & Coinsurance of Market HMO Select Silver - CLE-Care Health Insurance Plan, 99969OH0080432

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

Frequently Asked Questions(FAQ) about Market HMO Select Silver - CLE-Care, 99969OH0080432 Health Insurance Plan, 99969OH0080432

  • Does Market HMO Select Silver - CLE-Care Health Insurance Plan, 99969OH0080432 support Mail Ordering?

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

  • Does (99969OH0080432) Health Insurance Plan, Variant (99969OH0080432-01) offer Disease Management Programs?

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

    Does (99969OH0080432) Health Insurance Plan, Variant (99969OH0080432-01) have Out Of Country Coverage?

    Yes. Details: Emergency Only

    Does (99969OH0080432) Health Insurance Plan, Variant (99969OH0080432-01) have Out of Service Area Coverage?

    Yes. Details: Covered as Non-Network

    Does (99969OH0080432) Health Insurance Plan, Variant (99969OH0080432-01) offer Disease Management Programs?

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

    Does Market HMO Select Silver - CLE-Care Health Insurance Plan, Variant (99969OH0080432-01) offer Disease Management Programs for Asthma?

    Yes, the Market HMO Select Silver - CLE-Care Health Insurance Plan Variant 99969OH0080432-01 offers Disease Management Program for Asthma.

    Does Market HMO Select Silver - CLE-Care Health Insurance Plan, Variant (99969OH0080432-01) offer Disease Management Programs for Diabetes?

    Yes, the Market HMO Select Silver - CLE-Care Health Insurance Plan Variant 99969OH0080432-01 offers Disease Management Program for Diabetes.

 

Disclaimer: This is based on the import(Date: Tue, 02 Jul 2024 06:38 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