Navigator Silver 5000 - 23603MT0290008 Health Insurance Plan

PacificSource Health Plans health insurance plan with the Plan ID 23603MT0290008. The plan is called Navigator Silver 5000.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.15% (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 29.85% 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 23603MT0290008
Health Insurance Plan Year 2023
State Montana
Health Insurance Issuer PacificSource Health Plans
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 23603MT0290008-00
Provider Network(s) ['MTN003']
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 Montana 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 - 23603MT0290008-00

Standard On Exchange Plan - 23603MT0290008-01

Open to Indians below 300% FPL - 23603MT0290008-02

Open to Indians above 300% FPL - 23603MT0290008-03

73% AV Silver Plan - 23603MT0290008-04

87% AV Silver Plan - 23603MT0290008-05

94% AV Silver Plan - 23603MT0290008-06

Last Plan Update Date Fri, 30 Sep 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Navigator Silver 5000 Health Insurance Plan, 23603MT0290008-00

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

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Acupuncture

Limit: 12.0 Visit(s) per Year

Exclusions: Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies.

YES

$35.00

50.00% Coinsurance after deductible
Allergy Testing
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chiropractic Care

Limit: 10.0 Visit(s) per Benefit Period

Exclusions: Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies.

YES

$35.00

50.00% Coinsurance after deductible
Cosmetic Surgery
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dental Check-Up for Children
NO
Diabetes Education
YES

$35.00

50.00% Coinsurance after deductible
Dialysis
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Durable Medical Equipment
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Room Services

Exclusions: The benefit does not cover further treatment provided on referral from the emergency room.

For emergency medical conditions, out-of-network providers are paid at the in-network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.

YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.

YES

No Charge, 30.00% Coinsurance after deductible

No Charge, 30.00% Coinsurance after deductible
Gender Affirming Care

Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.

NO
Generic Drugs

Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Habilitation Services

See policy for more information.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Hearing Aids

The diagnosis and treatment of hearing loss and one amplification device for each ear every three years as required be an audiologist for members age 18 and younger.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Home Health Care Services
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Hospice Services
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infertility Treatment

Exclusions: Services and supplies for in vitro fertilization, erectile dysfunction, sexual dysfunction, or surgery to reverse voluntary sterilization. Services provided by out-of-network providers are not covered.

Treatment includes services to diagnose infertility, services related to artificial insemination.

YES

50.00% Coinsurance after deductible

100.00%
Infusion Therapy
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)

Exclusions: Charges for inpatient stays that began before you were covered by this plan.

Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

This health plan complies with all federal laws an regulations related to the Mental Health Parity and Addiction Equity Act of 2008.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services

This health plan complies with all federal laws an regulations related to the Mental Health Parity and Addiction Equity Act of 2008.

YES

$35.00

50.00% Coinsurance after deductible
Non-Preferred Brand Drugs

Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Nutritional Counseling
YES

$35.00

50.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$35.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Outpatient Rehabilitation Services

See policy for more information.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preferred Brand Drugs

Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Prenatal and Postnatal Care
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

No Charge

25.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness

Exclusions: Missed appointments and get acquainted visits. See policy for more information.

YES

$35.00

50.00% Coinsurance after deductible
Private-Duty Nursing

Exclusions: Private duty nurse not covered.

NO
Prosthetic Devices
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Radiation
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Reconstructive Surgery
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Rehabilitative Speech Therapy
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Benefit Period

Exclusions: Orthoptics, vision therapy, or other services to correct refractive error.

When using an in-network provider eye exams are covered in full. When using an out-of-network provider the first $40 is covered and the remaining cost is member responsibility.

YES

No Charge

Routine Foot Care
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

Exclusions: Confinement or custodial care is not covered. See policy for more information.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Specialist Visit

Exclusions: Missed appointments and get acquainted visits. See policy for more information.

YES

$70.00

50.00% Coinsurance after deductible
Specialty Drugs

Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
YES

$35.00

50.00% Coinsurance after deductible
Transplant
YES

No Charge after deductible

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$35.00

50.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

25.00%
X-rays and Diagnostic Imaging
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible

Navigator Silver 5000 Health Insurance Plan Variant 23603MT0290008-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.701516534
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, Diabetes, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID MTF007
Formulary URL URL
HIOS Product ID 23603MT029
Import Date 9/30/2022 20:01
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 23603
Issuer Marketplace Marketing Name PacificSource Health Plans
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 Yes
Network ID MTN003
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 Non-Participating Providers
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 23603MT0290008-00
Plan Marketing Name Navigator Silver 5000
Plan Type PPO
Plan Variant Marketing Name Navigator Silver 5000
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,300
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $5,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $300
SBC Scenario, Having Diabetes, Deductible $4,700
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID MTS001
Source Name SERFF
Plan ID 23603MT0290008
State Code MT
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 $10000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,000
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $20000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $10000 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $10,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $15200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7600 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,600
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $50000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $25000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $25,000
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of Navigator Silver 5000 Health Insurance Plan, 23603MT0290008

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

Frequently Asked Questions(FAQ) about Navigator Silver 5000, 23603MT0290008 Health Insurance Plan, 23603MT0290008

  • Does Navigator Silver 5000 Health Insurance Plan, 23603MT0290008 support Mail Ordering?

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

  • Does (23603MT0290008) Health Insurance Plan, Variant (23603MT0290008-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does (23603MT0290008) Health Insurance Plan, Variant (23603MT0290008-00) have Out Of Country Coverage?

    Yes. Details: Emergency Care Only

    Does (23603MT0290008) Health Insurance Plan, Variant (23603MT0290008-00) have Out of Service Area Coverage?

    Yes. Details: Non-Participating Providers

    Does (23603MT0290008) Health Insurance Plan, Variant (23603MT0290008-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy

    Does Navigator Silver 5000 Health Insurance Plan, Variant (23603MT0290008-00) offer Disease Management Programs for Asthma?

    Yes, the Navigator Silver 5000 Health Insurance Plan Variant 23603MT0290008-00 offers Disease Management Program for Asthma.

    Does Navigator Silver 5000 Health Insurance Plan, Variant (23603MT0290008-00) offer Disease Management Programs for Heart disease?

    Yes, the Navigator Silver 5000 Health Insurance Plan Variant 23603MT0290008-00 offers Disease Management Program for Heart disease.

    Does Navigator Silver 5000 Health Insurance Plan, Variant (23603MT0290008-00) offer Disease Management Programs for Diabetes?

    Yes, the Navigator Silver 5000 Health Insurance Plan Variant 23603MT0290008-00 offers Disease Management Program for Diabetes.

    Does Navigator Silver 5000 Health Insurance Plan, Variant (23603MT0290008-00) offer Disease Management Programs for Pregnancy?

    Yes, the Navigator Silver 5000 Health Insurance Plan Variant 23603MT0290008-00 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