AV Calculator Output Number | 0.780236057 |
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 | Standard Gold Off Exchange Plan |
Dental Only Plan | No |
Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 100% |
Formulary ID | MOF011 |
Formulary URL | URL |
HIOS Product ID | 99723MO009 |
Import Date | 8/13/2021 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 | Yes |
Is a Referral Required for Specialist? | No |
Issuer Actuarial Value | 77.39% |
Issuer ID | 99723 |
Issuer Marketplace Marketing Name | Ambetter from Home State Health |
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 | No |
Out of Service Area Coverage | No |
Plan Brochure | URL |
Plan Effective Date | 1/1/2022 |
Plan ID (Standard Component ID with Variant) | 99723MO0090064-00 |
Plan Marketing Name | Ambetter Secure Care 20 |
Plan Type | EPO |
Plan Variant Marketing Name | Ambetter Secure Care 20 |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $1,500 |
SBC Scenario, Having a Baby, Copayment | $300 |
SBC Scenario, Having a Baby, Deductible | $1,450 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $800 |
SBC Scenario, Having Diabetes, Deductible | $800 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,450 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | MOS002 |
Source Name | HIOS |
Plan ID | 99723MO0090064 |
State Code | MO |
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 | 35.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1500 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $750 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $750 |
TEHBDedOutOfNetFamilyPerGroup | per group not applicable |
TEHBDedOutOfNetFamilyPerPerson | 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 | $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 | Yes |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | No |