MVP Premier Plus Gold 10, Gold, NS, INN, NY Individual On Exchange HMO, Dep25, Acupuncture, Preferred Facilities, Telemedicine, Wellness, $0 PCP to age 26

56184NY0150097
Gold
HMO

MVP Premier Plus Gold 10, Gold, NS, INN, NY Individual On Exchange HMO, Dep25, Acupuncture, Preferred Facilities, Telemedicine, Wellness, $0 PCP to age 26 is a Gold HMO plan by MVP Health Plan, Inc..

Locations

MVP Premier Plus Gold 10, Gold, NS, INN, NY Individual On Exchange HMO, Dep25, Acupuncture, Preferred Facilities, Telemedicine, Wellness, $0 PCP to age 26 is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of MVP Premier Plus Gold 10, Gold, NS, INN, NY Individual On Exchange HMO, Dep25, Acupuncture, Preferred Facilities, Telemedicine, Wellness, $0 PCP to age 26 56184NY0150097.
Insurer: MVP Health Plan, Inc.
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 56184NY0150097

Cost-Sharing Overview

MVP Premier Plus Gold 10, Gold, NS, INN, NY Individual On Exchange HMO, Dep25, Acupuncture, Preferred Facilities, Telemedicine, Wellness, $0 PCP to age 26 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for MVP Premier Plus Gold 10, Gold, NS, INN, NY Individual On Exchange HMO, Dep25, Acupuncture, Preferred Facilities, Telemedicine, Wellness, $0 PCP to age 26?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

MVP Premier Plus Gold 10, Gold, NS, INN, NY Individual On Exchange HMO, Dep25, Acupuncture, Preferred Facilities, Telemedicine, Wellness, $0 PCP to age 26 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Low Back Pain
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what MVP Premier Plus Gold 10, Gold, NS, INN, NY Individual On Exchange HMO, Dep25, Acupuncture, Preferred Facilities, Telemedicine, Wellness, $0 PCP to age 26 covers when you are out of the service area or out of the country.

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
National Network: No

Additional Benefits and Cost-Sharing

MVP Premier Plus Gold 10, Gold, NS, INN, NY Individual On Exchange HMO, Dep25, Acupuncture, Preferred Facilities, Telemedicine, Wellness, $0 PCP to age 26 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No54 Visit(s) per Year 54 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery.Substituted
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Sterilization Procedures for Men
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Diabetic Equipment and Supplies
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Age 0-26 $0 Copayment not subject to Deductible, $35 Copayment not subject to Deductible for adults. Also includes 20 visits per year for family counseling.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Prostate Cancer Screening
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Bariatric Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery.
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Age 0-26 $0 Copayment not subject to Deductible, $35 Copayment not subject to Deductible for adults.
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Major Dental Care – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No54 Visit(s) per Year 54 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.Substituted
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per 3 Years Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years.
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No54 Visit(s) per Year 54 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery.Substituted
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No200 Days per Year
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Basic Dental Care – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Exam(s) per 6 Months One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.Dental Only Plan Available
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No One external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices)
Assistive Communication Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Inpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No60 Days per Year Additional EHB Benefit
Autologous Blood Banking
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No210 Days per Year Also includes 5 visits for family bereavement counseling.
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Dental Check-Up for Children
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Exam(s) per 6 Months Dental Only Plan Available
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Age 0-26 $0 Copayment not subject to Deductible, $35 Copayment not subject to Deductible for adults.
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Applied Behavior Analysis Based Therapies
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Age 0-26 $0 Copayment not subject to Deductible, $35 Copayment not subject to Deductible for adults.Additional EHB Benefit
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Age 0-26 $0 Copayment not subject to Deductible, $10 Copayment not subject to Deductible for adults.
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Age 0-26 $0 Copayment not subject to Deductible, $35 Copayment not subject to Deductible for adults.
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Nutritional Counseling
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year One prescribed lenses & frames in a 12-month period.
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Breast Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Second Opinion
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Orthodontia – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Family Planning Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No60 Visit(s) per Year Each visit of up to four hours by a home health aide is one visit.Substantially Equal
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Private-Duty Nursing
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No54 Visit(s) per Year Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care Professional’s office.Substituted
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Medical Supplies
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Preadmission Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Design
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No • $0 PCP and Generic Drugs age 0-26• $0 preventive care services, per recommended age and gender guidelines• Families are eligible for $1,000 for out-of-area coverage for Dependent Child Members up to age 26• At MVP Preferred Providers, lab, radiology, and ambulatory/outpatient surgery services received will be covered in full or after the deductible, if applicable• Access to MVP’s telemedicine services, including 24/7 urgent and emergency care, behavioral health, psychiatry, physical therapy, and more• Acupuncture Services, 12 visits per plan year• 20% savings on CVS-branded health related items• Plan includes Pediatric Vision Exams and Eyewear• $600 WellBeing Rewards• No referrals are required• The Deductible (if applicable) and Out-of-Pocket Maximum are EmbeddedNot EHB
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Exam(s) per Year
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Telemedicine
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Online internet consultations with a MVP approved telemedicine vendorAdditional EHB Benefit
Acupuncture
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No12 Visit(s) per Year Acupuncture is a method of treatment derived from ancient Chinese MedicineSubstantially Equal
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Cardiac Rehabilitation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Any visits for home infusion therapy count towards Your home health care visit limit.
Contact Lenses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Additional EHB Benefit
Gym Membership Reimbursement
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Earn up to $200 for gym membership and other reimbursable items. Additionally, receive up to $200 for completing health-related activities. Plus, earn up to $200 more for tracking your physical activity.Not EHB
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Cochlear Implants
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No One per ear per time coveredAdditional EHB Benefit
Abortion for Which Public Funding is Prohibited
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Procedure(s) per Year Not EHB

Free Preventive Services

There is no copayment or coinsurance for any of the following MVP Premier Plus Gold 10, Gold, NS, INN, NY Individual On Exchange HMO, Dep25, Acupuncture, Preferred Facilities, Telemedicine, Wellness, $0 PCP to age 26 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Ready to sign up for MVP Premier Plus Gold 10, Gold, NS, INN, NY Individual On Exchange HMO, Dep25, Acupuncture, Preferred Facilities, Telemedicine, Wellness, $0 PCP to age 26?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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