Core Care Bronze 4 - 79975MS0010005 Health Insurance Plan
Molina Healthcare of Mississippi, Inc health insurance plan with the Plan ID 79975MS0010005. The plan is called Core Care Bronze 4.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.26% (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 35.74% 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 | 79975MS0010005 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Mississippi | ||||||||||||||||||
| Health Insurance Issuer | Molina Healthcare of Mississippi, Inc | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 79975MS0010005-00 | ||||||||||||||||||
| Provider Network(s) | ['MSN001'] | ||||||||||||||||||
| 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 - 79975MS0010005-00 Standard On Exchange Plan - 79975MS0010005-01 |
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| Last Plan Update Date | Fri, 24 Feb 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Core Care Bronze 4 Health Insurance Plan, 79975MS0010005-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $1,750.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $50.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Must be medically necessary. Company may require a treatment plan, outlining the goals of therapy, mode of therapy, and duration of therapy, to be submitted by the provider prior to the initiation of treatment. |
YES | 50.00% |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year |
YES | $50.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Separate cost-sharing may apply for professional services. Maximum two days of facility copayments per inpatient admission. |
YES | $125.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Dialysis
|
YES | $125.00 |
100.00% |
| Durable Medical Equipment
|
YES | $500.00 |
100.00% |
| Emergency Room Services
|
YES | $1,750.00 |
$1,750.00 |
| Emergency Transportation/Ambulance
|
YES | $1,750.00 |
$1,750.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Limit: 30.0 Days per Month Coverage is limited to a 30-day supply retail or 90-day supply mail order. |
YES | $25.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year |
YES | $90.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | No Charge |
100.00% |
| Hospice Services
Limit: 6.0 Months per Lifetime |
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $1,500.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | $1,750.00 |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $1500.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $125.00 |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $75.00 |
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 | $1500.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $50.00 |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Days per Month Coverage is limited to a 30-day supply retail or 90-day supply mail order. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | $50.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $50.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $1,750.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Limited to 20 combined physical and occupational therapy visits per year, 20 speech therapy visits per year, and 36 cardiac rehabilitation visits per year. |
YES | $90.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $600.00 |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Days per Month Coverage is limited to a 30-day supply retail or 90-day supply mail order. |
YES | $125.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Covered services must be included in Grade A and B Recommendations of the USPSTF and include all other preventive health services required by PPACA. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $50.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | $500.00 |
100.00% |
| Radiation
Must be medically necessary. Company may require a treatment plan, outlining the goals of therapy, mode of therapy, and duration of therapy, to be submitted by the provider prior to the initiation of treatment. |
YES | $1,750.00 |
100.00% |
| Reconstructive Surgery
Plan only outlines benefits for breast reconstruction. Must be medically necessary and related to mastectomy. 2 copay max |
YES | $125.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Days per Year The 20 visit limit is combined for chiropractic services, occupational therapy, and physical therapy. |
YES | $90.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Not covered for learning disabilities and development problems. |
YES | $90.00 |
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 | No Charge |
100.00% |
| Routine Foot Care
Limit: 1.0 Visit(s) per Year Requires a Diabetes diagnosis. |
YES | $50.00 |
100.00% |
| Skilled Nursing Facility
Limit: 30.0 Days per Year |
YES | $1500.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $125.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Days per Month |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $1500.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $50.00 |
100.00% |
| Transplant
|
YES | $125.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | $600.00 |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $50.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $150.00 |
100.00% |
Core Care Bronze 4 Off Exchange Health Insurance Plan Variant 79975MS0010005-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.64257216 |
| 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 | Yes |
| CSR Variation Type | Standard Bronze Off 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 | $6000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3000 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $3,000 |
| 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, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | MSF003 |
| Formulary URL | URL |
| HIOS Product ID | 79975MS001 |
| Import Date | 2/24/2023 1:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 2 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 79975 |
| Issuer Marketplace Marketing Name | Molina Healthcare |
| 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, 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 | 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 Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 79975MS0010005-00 |
| Plan Marketing Name | Core Care Bronze 4 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Core Care Bronze 4 Off Exchange |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $2,700 |
| 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 | $3,300 |
| 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 | $2,300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MSS001 |
| Source Name | HIOS |
| Plan ID | 79975MS0010005 |
| 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 | $17100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8550 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,550 |
| 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 Core Care Bronze 4 Health Insurance Plan, 79975MS0010005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Core Care Bronze 4, 79975MS0010005 Health Insurance Plan, 79975MS0010005
-
Does Core Care Bronze 4 Health Insurance Plan, 79975MS0010005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (79975MS0010005) Health Insurance Plan, Variant (79975MS0010005-00) offer Disease Management Programs?
Does (79975MS0010005) Health Insurance Plan, Variant (79975MS0010005-00) have Out Of Country Coverage?
Does (79975MS0010005) Health Insurance Plan, Variant (79975MS0010005-00) have Out of Service Area Coverage?
Does (79975MS0010005) Health Insurance Plan, Variant (79975MS0010005-00) offer Disease Management Programs?
Does Core Care Bronze 4 Off Exchange Health Insurance Plan, Variant (79975MS0010005-00) offer Disease Management Programs for Asthma?
Does Core Care Bronze 4 Off Exchange Health Insurance Plan, Variant (79975MS0010005-00) offer Disease Management Programs for Heart disease?
Does Core Care Bronze 4 Off Exchange Health Insurance Plan, Variant (79975MS0010005-00) offer Disease Management Programs for Depression?
Does Core Care Bronze 4 Off Exchange Health Insurance Plan, Variant (79975MS0010005-00) offer Disease Management Programs for Diabetes?
Does Core Care Bronze 4 Off Exchange Health Insurance Plan, Variant (79975MS0010005-00) offer Disease Management Programs for High blood pressure & high cholesterol?
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