UHC Gold Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx) - 71667MI0010024 Health Insurance Plan

UnitedHealthcare Community Plan, Inc. health insurance plan with the Plan ID 71667MI0010024. The plan is called UHC Gold Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx).

Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.02% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.98% 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 79.05% (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 20.95% 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 71667MI0010024
Health Insurance Plan Year 2023
State Michigan
Health Insurance Issuer UnitedHealthcare Community Plan, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 71667MI0010024-00
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 - 71667MI0010024-00

Standard On Exchange Plan - 71667MI0010024-01

Open to Indians below 300% FPL - 71667MI0010024-02

Open to Indians above 300% FPL - 71667MI0010024-03

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

Benefits of UHC Gold Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx) Health Insurance Plan, 71667MI0010024-00

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

30% Coinsurance after deductible

100.00%
Bariatric Surgery

Limit: 1.0 Procedure(s) per Lifetime

Limited to one bariatric surgery per lifetime unless determined to be medically necessary to correct or reverse complications from a previous bariatric procedure.

YES

30% Coinsurance after deductible

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

Benefit limitations may apply to individual services.

YES

30% Coinsurance after deductible

100.00%
Chemotherapy
YES

30% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 30.0 Visit(s) per Year

Limit combined with Occupational and Physical Therapy.

YES

30% Coinsurance after deductible

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

Childbirth/delivery professional services follow inpatient physician/surgeon fees

YES

30% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

YES

No Charge

100.00%
Diabetes Education
YES

30% Coinsurance after deductible

100.00%
Dialysis
YES

30% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

30% Coinsurance after deductible

100.00%
Emergency Room Services
YES

30% Coinsurance after deductible

30% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

30% Coinsurance after deductible

30% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

30% Coinsurance after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs

Limit: 30.0 Days per Month

Lowest cost shares are available at preferred retail pharmacies and home delivery. See SBC for cost shares at other retail pharmacies and for non-preferred generics. 90-day supplies are available through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

YES

$1.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Year

Limited to 30 visits per year combined for Physical Therapy, Occupational Therapy and Manipulative Treatment; 30 visits per year for Speech Therapy. Visit limits for physical, occupational and speech therapies do not apply for Autism Spectrum Disorder.

YES

$50.00

100.00%
Hearing Aids
NO
Home Health Care Services
YES

30% Coinsurance after deductible

100.00%
Hospice Services

Coverage includes inpatient and outpatient hospice care.

YES

30% Coinsurance after deductible

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

$150.00

100.00%
Infertility Treatment

Exclusions: Health care services and related expenses for infertility treatments.

Covered only for diagnosis and services required to treat or correct underlying causes of infertility.

YES

30% Coinsurance after deductible

100.00%
Infusion Therapy
YES

30% Coinsurance after deductible

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

30% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

30% 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

Benefit limitations may apply to individual services.

YES

30% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

30% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$50.00

100.00%
Non-Preferred Brand Drugs

Limit: 30.0 Days per Month

Non-preferred brand medications are available in 90-day supplies through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

YES

30% Coinsurance after deductible

100.00%
Nutritional Counseling

Limit: 6.0 Visit(s) per Year

Consultations for dietitian services with a licensed dietitian are limited to 6 visits per year.

YES

30% Coinsurance after deductible

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

30% Coinsurance after deductible

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

$300.00

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Year

Limited to 30 visits per year combined for Physical Therapy, Occupational Therapy and Manipulative Treatment; 30 visits per year for Speech Therapy; 30 visits per year combined for Cardiac Rehabilitation Therapy and Pulmonary Rehabilitation Therapy. Visit limits for physical, occupational and speech therapies do not apply for Autism Spectrum Disorder.

YES

$50.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$300.00

100.00%
Preferred Brand Drugs

Limit: 30.0 Days per Month

Preferred brand medications are available in 90-day supplies through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

YES

$50.00

100.00%
Prenatal and Postnatal Care
YES

No Charge

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

Virtual urgent care visits via a Designated virtual provider unlimited $0

YES

No Charge

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

30% Coinsurance after deductible

100.00%
Radiation
YES

30% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

30% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Year

Limited to 30 visits per year combined for Physical Therapy, Occupational Therapy and Manipulative Treatment.

YES

$50.00

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Year

YES

$50.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 45.0 Days per Year

Limit will be any combination of Skilled Nursing Facility or Inpatient Rehabilitation Facility Services.

YES

30% Coinsurance after deductible

100.00%
Specialist Visit
YES

$50.00

100.00%
Specialty Drugs

Limit: 30.0 Days per Month

Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply.

YES

40% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

30% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$50.00

100.00%
Transplant
YES

30% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Benefits include services for diagnostic, surgical, and non-surgical treatment of temporomandibular joint and craniomandibular disorders.

YES

30% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$50.00

100.00%
Weight Loss Programs
YES

30% Coinsurance after deductible

100.00%
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$10.00

100.00%

UHC Gold-X Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx) Health Insurance Plan Variant 71667MI0010024-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.790536349
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 Not Applicable
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID MIF011
Formulary URL URL
HIOS Product ID 71667MI001
Import Date 9/12/2022 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? Yes
Issuer Actuarial Value 78.02%
Issuer ID 71667
Issuer Marketplace Marketing Name UnitedHealthcare
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 MIN001
Out of Country Coverage No
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area.
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 71667MI0010024-00
Plan Level Exclusions 0
Plan Marketing Name UHC Gold Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)
Plan Type HMO
Plan Variant Marketing Name UHC Gold-X Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,600
SBC Scenario, Having a Baby, Copayment $30
SBC Scenario, Having a Baby, Deductible $1,200
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $20
SBC Scenario, Having Diabetes, Copayment $700
SBC Scenario, Having Diabetes, Deductible $1,200
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $200
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,200
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID MIS001
Source Name SERFF
Specialist Requiring a Referral All, except OBGYN and as state mandated
Plan ID 71667MI0010024
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 $2400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1200 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,200
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 $18000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,000
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 Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of UHC Gold Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx) Health Insurance Plan, 71667MI0010024

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

Frequently Asked Questions(FAQ) about UHC Gold Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx), 71667MI0010024 Health Insurance Plan, 71667MI0010024

  • Does UHC Gold Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx) Health Insurance Plan, 71667MI0010024 support Mail Ordering?

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

  • Does (71667MI0010024) Health Insurance Plan, Variant (71667MI0010024-00) have Out Of Country Coverage?

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

    Does (71667MI0010024) Health Insurance Plan, Variant (71667MI0010024-00) have Out of Service Area Coverage?

    Yes. Details: Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area.

 

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