Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) - 93078IA0120055 Health Insurance Plan

Medica Insurance Company health insurance plan with the Plan ID 93078IA0120055. The plan is called Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.00% (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 22.00% 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 93078IA0120055
Health Insurance Plan Year 2023
State Iowa
Health Insurance Issuer Medica Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 93078IA0120055-00
Provider Network(s) ['IAN012']
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 Iowa 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 - 93078IA0120055-00

Standard On Exchange Plan - 93078IA0120055-01

Open to Indians below 300% FPL - 93078IA0120055-02

Open to Indians above 300% FPL - 93078IA0120055-03

Last Plan Update Date Wed, 17 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, 93078IA0120055-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited

Exclusions: Excludes abortions that are elective, except abortions performed when the life of the mother is at risk.

Elective, induced abortions are not covered, except as medically necessary to protect the life of the mother.

NO
Accidental Dental
YES

25.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

25.00% Coinsurance after deductible

100.00%
Bariatric Surgery
YES

25.00% Coinsurance after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

25.00% Coinsurance after deductible

100.00%
Chiropractic Care
YES

$30.00

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

25.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

25.00% Coinsurance after deductible

100.00%
Dialysis
YES

25.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

25.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

25.00% Coinsurance after deductible

100.00%
Gender Affirming Care
YES

25.00% Coinsurance after deductible

100.00%
Generic Drugs
YES

$15.00

100.00%
Habilitation Services

Treatment for Autism with speech therapy, occupational therapy, or physical therapy is covered.

YES

25.00% Coinsurance after deductible

100.00%
Hearing Aids
NO
Home Health Care Services
YES

25.00% Coinsurance after deductible

100.00%
Hospice Services

Care (generally in a home setting) for patients who are terminally ill and who have a life expectancy of six months or less. Hospice respite care has a quantity limit of 15 inpatient days and 15 outpatient days per lifetime. Hospice respite care must be used in increments of not more than five days at a time.

YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Infertility Treatment

Exclusions: Artificial insemination, in vitro fertilization and other limitations and exclusions apply.

YES

25.00% Coinsurance after deductible

100.00%
Infusion Therapy
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$30.00

100.00%
Non-Preferred Brand Drugs
YES

$60.00

100.00%
Nutritional Counseling
NO
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$30.00

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

25.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services
YES

25.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Prescription insulin will not exceed $25 per prescription unit

YES

$30.00

100.00%
Prenatal and Postnatal Care
YES

25.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

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

$30.00

100.00%
Private-Duty Nursing

Plan refers to home skilled nursing as private duty nursing. Home skilled nursing is intended to provide a safe transition from other levels of care when medically necessary, to provide teaching to caregivers for ongoing care, or to provide short-term treatments that can be safely administered in the home setting.

YES

25.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

25.00% Coinsurance after deductible

100.00%
Radiation
YES

25.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

25.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

$30.00

100.00%
Rehabilitative Speech Therapy
YES

$30.00

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

$30.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility
YES

25.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$60.00

100.00%
Specialty Drugs
YES

$250.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

25.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$30.00

100.00%
Transplant
YES

25.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

25.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$45.00

$45.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

25.00% Coinsurance after deductible

100.00%

Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 93078IA0120055-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.780017779
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 Gold Off Exchange Plan
Dental Only Plan No
Design Type Design 1
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 IAF028
Formulary URL URL
HIOS Product ID 93078IA012
Import Date 8/17/2022 20:01
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 93078
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 IAN012
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) 93078IA0120055-00
Plan Marketing Name Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers)
Plan Type EPO
Plan Variant Marketing Name Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,300
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $2,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $700
SBC Scenario, Having Diabetes, Deductible $1,100
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $100
SBC Scenario, Treatment of a Simple Fracture, Copayment $100
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,000
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID IAS012
Source Name SERFF
Plan ID 93078IA0120055
State Code IA
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 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $4000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $2000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $2,000
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 $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
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 Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, 93078IA0120055

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

Frequently Asked Questions(FAQ) about Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers), 93078IA0120055 Health Insurance Plan, 93078IA0120055

  • Does Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, 93078IA0120055 support Mail Ordering?

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

  • Does (93078IA0120055) Health Insurance Plan, Variant (93078IA0120055-00) 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 (93078IA0120055) Health Insurance Plan, Variant (93078IA0120055-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services

    Does (93078IA0120055) Health Insurance Plan, Variant (93078IA0120055-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services

    Does (93078IA0120055) Health Insurance Plan, Variant (93078IA0120055-00) 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 Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (93078IA0120055-00) offer Disease Management Programs for Asthma?

    Yes, the Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 93078IA0120055-00 offers Disease Management Program for Asthma.

    Does Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (93078IA0120055-00) offer Disease Management Programs for Heart disease?

    Yes, the Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 93078IA0120055-00 offers Disease Management Program for Heart disease.

    Does Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (93078IA0120055-00) offer Disease Management Programs for Depression?

    Yes, the Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 93078IA0120055-00 offers Disease Management Program for Depression.

    Does Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (93078IA0120055-00) offer Disease Management Programs for Diabetes?

    Yes, the Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 93078IA0120055-00 offers Disease Management Program for Diabetes.

    Does Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (93078IA0120055-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 93078IA0120055-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (93078IA0120055-00) offer Disease Management Programs for Low back pain?

    Yes, the Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 93078IA0120055-00 offers Disease Management Program for Low back pain.

    Does Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (93078IA0120055-00) offer Disease Management Programs for Pregnancy?

    Yes, the Empower by Medica Gold Standard ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 93078IA0120055-00 offers Disease Management Program for Pregnancy.

 

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