Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) - 53461MO0010045 Health Insurance Plan
Medica Insurance Company health insurance plan with the Plan ID 53461MO0010045. The plan is called Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 53461MO0010045 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Missouri | ||||||||||||||||||
| Health Insurance Issuer | Medica Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 53461MO0010045-02 | ||||||||||||||||||
| Provider Network(s) | ['MON001'] | ||||||||||||||||||
| 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 - 53461MO0010045-00 Standard On Exchange Plan - 53461MO0010045-01 |
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| Last Plan Update Date | Wed, 17 Aug 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, 53461MO0010045-02
| 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 | 0.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 0.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 0.00% |
100.00% |
| Chiropractic Care
|
YES | $0.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 0.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 0.00% |
100.00% |
| Dialysis
|
YES | 0.00% |
100.00% |
| Durable Medical Equipment
|
YES | 0.00% |
100.00% |
| Emergency Room Services
|
YES | 0.00% |
0.00% |
| Emergency Transportation/Ambulance
|
YES | 0.00% |
0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Covered lenses and frames each available at limit of one per year. |
YES | 0.00% |
100.00% |
| Gender Affirming Care
|
YES | 0.00% |
100.00% |
| Generic Drugs
Tier 1 preferred generic drugs on Medica's Drug List are $0 and tier 2 generic drugs are $15. Go to Plan Documents to see the List of Covered Drugs. |
YES | $0.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Benefit Period This visit limit does not apply to services for mental health conditions or substance use disorders. |
YES | 0.00% |
100.00% |
| Hearing Aids
Benefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening. |
YES | 0.00% |
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 | 0.00% |
100.00% |
| Hospice Services
|
YES | 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 0.00% |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 0.00% |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $0.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 0.00% |
100.00% |
| Nutritional Counseling
|
YES | 0.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 0.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Benefit Period |
YES | 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 0.00% |
100.00% |
| Preferred Brand Drugs
Prescription insulin will not exceed $25 per prescription unit |
YES | $0.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $0.00 |
100.00% |
| Private-Duty Nursing
Limit: 82.0 Visit(s) per Benefit Period |
YES | 0.00% |
100.00% |
| Prosthetic Devices
|
YES | 0.00% |
100.00% |
| Radiation
|
YES | 0.00% |
100.00% |
| Reconstructive Surgery
|
YES | 0.00% |
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 | 0.00% |
100.00% |
| Rehabilitative Speech Therapy
Unlimited visits for speech therapy. |
YES | 0.00% |
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 | $0.00 |
100.00% |
| Routine Foot Care
Coverage is available if Medically Necessary. |
YES | 0.00% |
100.00% |
| Skilled Nursing Facility
Limit: 150.0 Days per Benefit Period |
YES | 0.00% |
100.00% |
| Specialist Visit
|
YES | $0.00 |
100.00% |
| Specialty Drugs
|
YES | $0.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $0.00 |
100.00% |
| Transplant
|
YES | 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 0.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $0.00 |
$0.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 0.00% |
100.00% |
Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 53461MO0010045-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1 |
| 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 | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | MOF023 |
| Formulary URL | URL |
| HIOS Product ID | 53461MO001 |
| Import Date | 8/17/2022 1:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| 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 ID | 53461 |
| Issuer Marketplace Marketing Name | Medica |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MON001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 53461MO0010045-02 |
| Plan Marketing Name | Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) |
| Plan Type | EPO |
| Plan Variant Marketing Name | Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MOS001 |
| Source Name | HIOS |
| Plan ID | 53461MO0010045 |
| State Code | MO |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, 53461MO0010045
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers), 53461MO0010045 Health Insurance Plan, 53461MO0010045
-
Does Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, 53461MO0010045 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (53461MO0010045) Health Insurance Plan, Variant (53461MO0010045-02) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Does (53461MO0010045) Health Insurance Plan, Variant (53461MO0010045-02) have Out Of Country Coverage?
Yes. Details: Emergency Services
Does (53461MO0010045) Health Insurance Plan, Variant (53461MO0010045-02) have Out of Service Area Coverage?
Yes. Details: Emergency Services
Does (53461MO0010045) Health Insurance Plan, Variant (53461MO0010045-02) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Does Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (53461MO0010045-02) offer Disease Management Programs for Asthma?
Yes, the Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant
53461MO0010045-02 offers Disease
Management Program for Asthma.
Does Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (53461MO0010045-02) offer Disease Management Programs for Heart disease?
Yes, the Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant
53461MO0010045-02 offers Disease
Management Program for Heart disease.
Does Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (53461MO0010045-02) offer Disease Management Programs for Depression?
Yes, the Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant
53461MO0010045-02 offers Disease
Management Program for Depression.
Does Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (53461MO0010045-02) offer Disease Management Programs for Diabetes?
Yes, the Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant
53461MO0010045-02 offers Disease
Management Program for Diabetes.
Does Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (53461MO0010045-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant
53461MO0010045-02 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (53461MO0010045-02) offer Disease Management Programs for Low back pain?
Yes, the Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant
53461MO0010045-02 offers Disease
Management Program for Low back pain.
Does Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (53461MO0010045-02) offer Disease Management Programs for Pregnancy?
Yes, the Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant
53461MO0010045-02 offers Disease
Management Program for Pregnancy.
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