Bronze Connect 1 - 96384MO0220001 Health Insurance Plan

Cox Health Systems Insurance Company health insurance plan with the Plan ID 96384MO0220001. The plan is called Bronze Connect 1.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 62.79% (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 37.21% 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 96384MO0220001
Health Insurance Plan Year 2023
State Missouri
Health Insurance Issuer Cox Health Systems Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 96384MO0220001-00
Provider Network(s) ['MON002']
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 Missouri 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 - 96384MO0220001-00

Standard On Exchange Plan - 96384MO0220001-01

Open to Indians below 300% FPL - 96384MO0220001-02

Open to Indians above 300% FPL - 96384MO0220001-03

Last Plan Update Date Wed, 28 Sep 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Bronze Connect 1 Health Insurance Plan, 96384MO0220001-00

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% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

0.00% Coinsurance after deductible

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

0.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

0.00% Coinsurance after deductible

100.00%
Chiropractic Care

Chiropractic visits beyond 26 per benefit period require Prior Authorization.

YES

0.00% Coinsurance after deductible

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

0.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

YES

0.00% Coinsurance after deductible

100.00%
Diabetes Education
YES

0.00% Coinsurance after deductible

100.00%
Dialysis

Covered Services include dialysis treatments in an outpatient dialysis, or home dialysis and training for you and the person who will help you with home self-dialysis.

YES

0.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

0.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
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% Coinsurance after deductible

100.00%
Gender Affirming Care
YES

0.00% Coinsurance after deductible

100.00%
Generic Drugs
YES

$20.00

100.00%
Habilitation Services

Limit: 20.0 Visit(s) per Benefit Period

Habilitative services definition: 'help you keep, learn or improve skills and functioning for daily living.'

YES

0.00% Coinsurance after deductible

100.00%
Hearing Aids

Benefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening.

YES

0.00% Coinsurance after deductible

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% Coinsurance after deductible

100.00%
Hospice Services
YES

0.00% Coinsurance after deductible

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

0.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

0.00% Coinsurance after deductible

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

0.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

0.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

0.00% Coinsurance after deductible

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

0.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

0.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

0.00% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs
YES

0.00% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

0.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Limit: 1.0 Procedure(s) per Lifetime

YES

0.00% Coinsurance after deductible

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

0.00% Coinsurance after deductible

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

0.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Benefit Period

To be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing toward those goals.

YES

0.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

0.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

0.00% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care
YES

0.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

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

0.00% Coinsurance after deductible

100.00%
Private-Duty Nursing

Limit: 82.0 Visit(s) per Benefit Period

Private duty nursing services are a Covered Service only when given as part of the 'Home Care Services' benefit. Private Duty Lifetime Maximum: 164 visits In- and Out-of-Network combined.

YES

0.00% Coinsurance after deductible

100.00%
Prosthetic Devices

Benefits include the purchase, fitting, adjustments, repairs and replacements.

YES

0.00% Coinsurance after deductible

100.00%
Radiation
YES

0.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance.

YES

0.00% Coinsurance after deductible

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% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Unlimited visits for speech therapy.

YES

0.00% Coinsurance after deductible

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% Coinsurance after deductible

100.00%
Routine Foot Care

Coverage is available if Medically Necessary.

YES

0.00% Coinsurance after deductible

100.00%
Skilled Nursing Facility

Limit: 150.0 Days per Benefit Period

Limit is for in-and out-of-network combined and includes rehab and outpatient day rehab.

YES

0.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

0.00% Coinsurance after deductible

100.00%
Specialty Drugs
YES

0.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

0.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

0.00% Coinsurance after deductible

100.00%
Transplant
YES

0.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.

YES

0.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

0.00% Coinsurance after deductible

100.00%

Bronze Connect 1 Health Insurance Plan Variant 96384MO0220001-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.627916485
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 Bronze Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID MOF007
Formulary URL URL
HIOS Product ID 96384MO022
Import Date 9/28/2022 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 96384
Issuer Marketplace Marketing Name Cox HealthPlans
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID MON002
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) 96384MO0220001-00
Plan Marketing Name Bronze Connect 1
Plan Type EPO
Plan Variant Marketing Name Bronze Connect 1
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $8,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $100
SBC Scenario, Having Diabetes, Deductible $5,100
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $10
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID MOS002
Source Name HIOS
Plan ID 96384MO0220001
State Code MO
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $16000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $8000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $8,000
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $16000 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $8000 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $8,000
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 $16000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $8000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $8,000
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person 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 $16000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,000
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 No

Copay & Coinsurance of Bronze Connect 1 Health Insurance Plan, 96384MO0220001

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

Frequently Asked Questions(FAQ) about Bronze Connect 1, 96384MO0220001 Health Insurance Plan, 96384MO0220001

  • Does Bronze Connect 1 Health Insurance Plan, 96384MO0220001 support Mail Ordering?

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

  • Does (96384MO0220001) Health Insurance Plan, Variant (96384MO0220001-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (96384MO0220001) Health Insurance Plan, Variant (96384MO0220001-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

 

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