Essential Gold 1600 - 14624MS0010002 Health Insurance Plan

Primewell Health Services of Mississippi, Inc. health insurance plan with the Plan ID 14624MS0010002. The plan is called Essential Gold 1600.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 76.20% (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 23.80% 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 14624MS0010002
Health Insurance Plan Year 2022
State Mississippi
Health Insurance Issuer Primewell Health Services of Mississippi, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 14624MS0010002-03
Provider Network(s) ['MSN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 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 - 14624MS0010002-00

Standard On Exchange Plan - 14624MS0010002-01

Open to Indians below 300% FPL - 14624MS0010002-02

Open to Indians above 300% FPL - 14624MS0010002-03

Last Plan Update Date Wed, 11 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Essential Gold 1600 Limited Health Insurance Plan Variant 14624MS0010002-03 Attributes

Plan Attribute Value
AV Calculator Output Number 0.761979664
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Limited Cost Sharing Plan Variation
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 20.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $1800 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $600 per person
Drug EHB Deductible, In Network (Tier 1), Individual $600
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
Disease Management Programs Offered Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Weight Loss Programs
EHB Percent of Total Premium 0.9697439
First Tier Utilization 100%
Formulary ID MSF001
Formulary URL URL
HIOS Product ID 14624MS001
Import Date 8/11/2021 1:00
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 Yes
Is a Referral Required for Specialist? No
Issuer ID 14624
Issuer Marketplace Marketing Name Vantage Health Plan of Mississippi
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 20.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $4800 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $1600 per person
Medical EHB Deductible, In Network (Tier 1), Individual $1,600
Medical EHB Deductible, Out of Network, Family Per Group $15000 per group
Medical EHB Deductible, Out of Network, Family Per Person $5000 per person
Medical EHB Deductible, Out of Network, Individual $5,000
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID MSN001
Out of Country Coverage Yes
Out of Country Coverage Description Limited to Emergency Services only. Covered as in-network.
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Out-of-Network Deductible and Co-insurance
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan ID (Standard Component ID with Variant) 14624MS0010002-03
Plan Marketing Name Essential Gold 1600
Plan Type POS
Plan Variant Marketing Name Essential Gold 1600 Limited
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,700
SBC Scenario, Having a Baby, Copayment $40
SBC Scenario, Having a Baby, Deductible $1,600
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $600
SBC Scenario, Having Diabetes, Copayment $400
SBC Scenario, Having Diabetes, Deductible $1,500
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $200
SBC Scenario, Treatment of a Simple Fracture, Copayment $10
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,600
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID MSS001
Source Name HIOS
Plan ID 14624MS0010002
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
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $15000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,500
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 Essential Gold 1600 Health Insurance Plan, 14624MS0010002

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

Frequently Asked Questions(FAQ) about Essential Gold 1600, 14624MS0010002 Health Insurance Plan, 14624MS0010002

  • Does Essential Gold 1600 Health Insurance Plan, 14624MS0010002 support Mail Ordering?

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

  • Does (14624MS0010002) Health Insurance Plan, Variant (14624MS0010002-03) offer Disease Management Programs?

    Yes, and here is the list of available programs: Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Weight Loss Programs

    Does (14624MS0010002) Health Insurance Plan, Variant (14624MS0010002-03) have Out Of Country Coverage?

    Yes. Details: Limited to Emergency Services only. Covered as in-network.

    Does (14624MS0010002) Health Insurance Plan, Variant (14624MS0010002-03) have Out of Service Area Coverage?

    Yes. Details: Out-of-Network Deductible and Co-insurance

    Does (14624MS0010002) Health Insurance Plan, Variant (14624MS0010002-03) offer Disease Management Programs?

    Yes, and here is the list of available programs: Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Weight Loss Programs

    Does Essential Gold 1600 Limited Health Insurance Plan, Variant (14624MS0010002-03) offer Disease Management Programs for Heart disease?

    Yes, the Essential Gold 1600 Limited Health Insurance Plan Variant 14624MS0010002-03 offers Disease Management Program for Heart disease.

    Does Essential Gold 1600 Limited Health Insurance Plan, Variant (14624MS0010002-03) offer Disease Management Programs for Depression?

    Yes, the Essential Gold 1600 Limited Health Insurance Plan Variant 14624MS0010002-03 offers Disease Management Program for Depression.

    Does Essential Gold 1600 Limited Health Insurance Plan, Variant (14624MS0010002-03) offer Disease Management Programs for Diabetes?

    Yes, the Essential Gold 1600 Limited Health Insurance Plan Variant 14624MS0010002-03 offers Disease Management Program for Diabetes.

    Does Essential Gold 1600 Limited Health Insurance Plan, Variant (14624MS0010002-03) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Essential Gold 1600 Limited Health Insurance Plan Variant 14624MS0010002-03 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Essential Gold 1600 Limited Health Insurance Plan, Variant (14624MS0010002-03) offer Disease Management Programs for Weight loss programs?

    Yes, the Essential Gold 1600 Limited Health Insurance Plan Variant 14624MS0010002-03 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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