MyPriority Travel Silver 5500 - 29698MI0540667 Health Insurance Plan

Priority Health health insurance plan with the Plan ID 29698MI0540667. The plan is called MyPriority Travel Silver 5500.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.70% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.30% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.30% (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 26.70% 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 29698MI0540667
Health Insurance Plan Year 2023
State Michigan
Health Insurance Issuer Priority Health
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 29698MI0540667-00
Provider Network(s) ['MIN001']
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 Michigan 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 - 29698MI0540667-00

Standard On Exchange Plan - 29698MI0540667-01

Open to Indians below 300% FPL - 29698MI0540667-02

Open to Indians above 300% FPL - 29698MI0540667-03

73% AV Silver Plan - 29698MI0540667-04

87% AV Silver Plan - 29698MI0540667-05

94% AV Silver Plan - 29698MI0540667-06

Last Plan Update Date Tue, 20 Dec 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of MyPriority Travel Silver 5500 Health Insurance Plan, 29698MI0540667-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
NO
Acupuncture
NO
Allergy Testing
YES

30.00% Coinsurance after deductible

100.00%
Applied Behavior Analysis Based Therapies

Only covered in relation to Autism Spectrum Disorder.

YES

30.00% Coinsurance after deductible

100.00%
Autism Spectrum Disorders

Only covered in relation to Autism Spectrum Disorder.

YES

30.00% Coinsurance after deductible

100.00%
Bariatric Surgery

Limit: 1.0 Procedure(s) per Lifetime

One procedure per lifetime.

YES

50.00% Coinsurance after deductible

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

30.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 30.0 Visit(s) per Year

Maximum 30 visits per member per year combined with rehabilitative occupational and physical therapy.

YES

30.00% Coinsurance after deductible

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

30.00% Coinsurance after deductible

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

No Charge

100.00%
Dialysis
YES

30.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

50.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

$250.00 Copay after deductible, 30.00% Coinsurance after deductible

$250.00 Copay after deductible, 30.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

$250.00 Copay after deductible, 30.00% Coinsurance after deductible

$250.00 Copay after deductible, 30.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

One select eyeglass frame and one set of lenses, or provider designated contact lenses in lieu of eyeglass frames and lenses, per year.

YES

No Charge

100.00%
Gender Affirming Care
YES

30.00% Coinsurance after deductible

100.00%
Generic Drugs

Refer to the drug list for quantity limits and other exclusions.

YES

$5.00

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Year

Up to 60 visits per year: limited to 30 speech therapy visits and 30 occupational and physical therapy rehabilitation visits per member per year (non-Autism Spectrum Disorder). See SBC for details.

YES

30.00% Coinsurance after deductible

100.00%
Hearing Aids
NO
Home Health Care Services

Including hospice care in the home.

YES

30.00% Coinsurance after deductible

100.00%
Hospice Services
YES

30.00% Coinsurance after deductible

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

$150.00 Copay after deductible, 30.00% Coinsurance after deductible

100.00%
Infertility Treatment

Limits and exclusions apply. Diagnosis and treatment of underlying cause only. See SBC document.

YES

50.00% Coinsurance after deductible

100.00%
Infusion Therapy
YES

30.00% Coinsurance after deductible

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

30.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

$10.00

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

30.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$30.00

100.00%
Non-Preferred Brand Drugs

Refer to the drug list for quantity limits and other exclusions.

YES

$125.00

100.00%
Nutritional Counseling

Limit: 6.0 Visit(s) per Year

Maximum of six visits per year of nutritional counseling/dietician services.

YES

No Charge

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

$65.00

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

$1000.00 Copay after deductible, 30.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 90.0 Visit(s) per Year

Up to 90 visits per year: limited to 30 speech therapy visits, 30 occupational and physical therapy, and 30 cardiac and pulmonary rehabilitation visits per member per year. See SBC for details.

YES

30.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Refer to the drug list for quantity limits and other exclusions.

YES

$75.00

100.00%
Prenatal and Postnatal Care

Routine care is covered as preventive. Complications of Pregnancy is diagnostic/medical care will be covered as indicated by the SBC document.

YES

No Charge

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

This plan includes one annual physical/wellness exam at no cost to the member.

YES

$30.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

50.00% Coinsurance after deductible

100.00%
Radiation
YES

30.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

30.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Year

Combined maximum of 30 visits per year. Combined with Chiropractic Care

YES

30.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Year

Maximum of 30 visits per year.

YES

30.00% 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 Year

One exam per year. See SBC for details.

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 45.0 Days per Year

Up to 45 days per benefit period. This limit is combined with hospice facility, subacute facility, and inpatient rehabilitation care facility services.

YES

30.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$65.00

100.00%
Specialty Drugs

Refer to the drug list for quantity limits and other exclusions.

YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

30.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$0.00

100.00%
Transplant
YES

30.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Coverage includes medical care or services to treat dysfunction or TMJS resulting from a medical cause or Injury, Office visits for medical evaluation and treatment, X-rays of the temporomandibular joint including contrast studies, but not dental x-rays, Myofunctional therapy and Surgery to the temporomandibular joint, such as condylectomy, meniscectomy, arthrotomy, and arthrocentesis.

YES

30.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$75.00

100.00%
Weight Loss Programs
YES

30.00% Coinsurance after deductible

100.00%
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

30.00% Coinsurance after deductible

100.00%

MyPriority Travel Silver 5500 Health Insurance Plan Variant 29698MI0540667-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.732958485
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 Silver Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID MIF005
Formulary URL URL
HIOS Product ID 29698MI054
Import Date 12/20/2022 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 Actuarial Value 71.70%
Issuer ID 29698
Issuer Marketplace Marketing Name Priority Health
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID MIN001
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Care Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Urgent/Emergency Care Only
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 29698MI0540667-00
Plan Marketing Name MyPriority Travel Silver 5500
Plan Type HMO
Plan Variant Marketing Name MyPriority Travel Silver 5500
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,800
SBC Scenario, Having a Baby, Copayment $200
SBC Scenario, Having a Baby, Deductible $5,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,600
SBC Scenario, Having Diabetes, Deductible $800
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID MIS001
Source Name SERFF
Plan ID 29698MI0540667
State Code MI
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 30.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $11000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,500
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 $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,100
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

Copay & Coinsurance of MyPriority Travel Silver 5500 Health Insurance Plan, 29698MI0540667

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

Frequently Asked Questions(FAQ) about MyPriority Travel Silver 5500, 29698MI0540667 Health Insurance Plan, 29698MI0540667

  • Does MyPriority Travel Silver 5500 Health Insurance Plan, 29698MI0540667 support Mail Ordering?

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

  • Does (29698MI0540667) Health Insurance Plan, Variant (29698MI0540667-00) 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, Weight Loss Programs

    Does (29698MI0540667) Health Insurance Plan, Variant (29698MI0540667-00) have Out Of Country Coverage?

    Yes. Details: Emergency Care Only

    Does (29698MI0540667) Health Insurance Plan, Variant (29698MI0540667-00) have Out of Service Area Coverage?

    Yes. Details: Urgent/Emergency Care Only

    Does (29698MI0540667) Health Insurance Plan, Variant (29698MI0540667-00) 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, Weight Loss Programs

    Does MyPriority Travel Silver 5500 Health Insurance Plan, Variant (29698MI0540667-00) offer Disease Management Programs for Asthma?

    Yes, the MyPriority Travel Silver 5500 Health Insurance Plan Variant 29698MI0540667-00 offers Disease Management Program for Asthma.

    Does MyPriority Travel Silver 5500 Health Insurance Plan, Variant (29698MI0540667-00) offer Disease Management Programs for Heart disease?

    Yes, the MyPriority Travel Silver 5500 Health Insurance Plan Variant 29698MI0540667-00 offers Disease Management Program for Heart disease.

    Does MyPriority Travel Silver 5500 Health Insurance Plan, Variant (29698MI0540667-00) offer Disease Management Programs for Depression?

    Yes, the MyPriority Travel Silver 5500 Health Insurance Plan Variant 29698MI0540667-00 offers Disease Management Program for Depression.

    Does MyPriority Travel Silver 5500 Health Insurance Plan, Variant (29698MI0540667-00) offer Disease Management Programs for Diabetes?

    Yes, the MyPriority Travel Silver 5500 Health Insurance Plan Variant 29698MI0540667-00 offers Disease Management Program for Diabetes.

    Does MyPriority Travel Silver 5500 Health Insurance Plan, Variant (29698MI0540667-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the MyPriority Travel Silver 5500 Health Insurance Plan Variant 29698MI0540667-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does MyPriority Travel Silver 5500 Health Insurance Plan, Variant (29698MI0540667-00) offer Disease Management Programs for Low back pain?

    Yes, the MyPriority Travel Silver 5500 Health Insurance Plan Variant 29698MI0540667-00 offers Disease Management Program for Low back pain.

    Does MyPriority Travel Silver 5500 Health Insurance Plan, Variant (29698MI0540667-00) offer Disease Management Programs for Pregnancy?

    Yes, the MyPriority Travel Silver 5500 Health Insurance Plan Variant 29698MI0540667-00 offers Disease Management Program for Pregnancy.

    Does MyPriority Travel Silver 5500 Health Insurance Plan, Variant (29698MI0540667-00) offer Disease Management Programs for Weight loss programs?

    Yes, the MyPriority Travel Silver 5500 Health Insurance Plan Variant 29698MI0540667-00 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