| Field | Data |
|---|---|
| Health Insurance Plan ID | 47840MO0010006 |
| Health Insurance Plan Year | 2023 |
| State | Missouri |
| Health Insurance Issuer | SSM Health Insurance Company |
| Plan Marketing Materials URL | Marketing URL |
| Last Plan Update Date | Sun, 30 Apr 2023 00:00 GMT |
| Last Import Date | Sun, 28 May 2023 07:51 GMT |
| Health Insurance Plan Variant | 47840MO0010006-03 |
| Available Variants of the Health Plan | |
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.701100174 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 3 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| DEHBDedOutOfNetFamilyPerGroup | per group not applicable |
| DEHBDedOutOfNetFamilyPerPerson | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| 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 | MOF003 |
| Formulary URL | URL |
| HIOS Product ID | 47840MO001 |
| Import Date | 8/18/2022 1:00 |
| 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 | 47840 |
| Issuer Marketplace Marketing Name | WellFirst Health |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $8200 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $4100 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $4,100 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MON001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Only |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 47840MO0010006-03 |
| Plan Level Exclusions | See policy or plan document for additional excluded services. |
| Plan Marketing Name | WellFirst Silver Value Copay 4100X (Free Virtual Visits & Transportation) |
| Plan Type | EPO |
| Plan Variant Marketing Name | WellFirst Silver Value Copay 4100X (Free Virtual Visits & Transportation) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MOS001 |
| Source Name | HIOS |
| Plan ID | 47840MO0010006 |
| State Code | MO |
| 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 |
| 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 |
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about WellFirst Silver Value Copay 4100X, 47840MO0010006 Health Insurance Plan, 47840MO0010006
Does WellFirst Silver Value Copay 4100X Health Insurance Plan, 47840MO0010006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (47840MO0010006) Health Insurance Plan, Variant (47840MO0010006-03) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy
Does (47840MO0010006) Health Insurance Plan, Variant (47840MO0010006-03) have Out Of Country Coverage?
Yes. Details: Emergency Only
Does (47840MO0010006) Health Insurance Plan, Variant (47840MO0010006-03) have Out of Service Area Coverage?
Yes. Details: Emergency Only
Does (47840MO0010006) Health Insurance Plan, Variant (47840MO0010006-03) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy
Does WellFirst Silver Value Copay 4100X (Free Virtual Visits & Transportation) Health Insurance Plan, Variant (47840MO0010006-03) offer Disease Management Programs for Asthma?
Yes, the WellFirst Silver Value Copay 4100X (Free Virtual Visits & Transportation) Health Insurance Plan Variant 47840MO0010006-03 offers Disease Management Program for Asthma.
Does WellFirst Silver Value Copay 4100X (Free Virtual Visits & Transportation) Health Insurance Plan, Variant (47840MO0010006-03) offer Disease Management Programs for Heart disease?
Yes, the WellFirst Silver Value Copay 4100X (Free Virtual Visits & Transportation) Health Insurance Plan Variant 47840MO0010006-03 offers Disease Management Program for Heart disease.
Does WellFirst Silver Value Copay 4100X (Free Virtual Visits & Transportation) Health Insurance Plan, Variant (47840MO0010006-03) offer Disease Management Programs for Diabetes?
Yes, the WellFirst Silver Value Copay 4100X (Free Virtual Visits & Transportation) Health Insurance Plan Variant 47840MO0010006-03 offers Disease Management Program for Diabetes.
Does WellFirst Silver Value Copay 4100X (Free Virtual Visits & Transportation) Health Insurance Plan, Variant (47840MO0010006-03) offer Disease Management Programs for Pregnancy?
Yes, the WellFirst Silver Value Copay 4100X (Free Virtual Visits & Transportation) Health Insurance Plan Variant 47840MO0010006-03 offers Disease Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Sun, 28 May 2023 07:51 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